What to assess in a patient with epistaxis (nosebleed)?

Assessment of Epistaxis

When evaluating a patient with epistaxis, immediately assess for airway compromise and hemodynamic instability (tachycardia, hypotension, syncope, orthostatic changes) to determine if emergent hospital-level care is required, then systematically identify the bleeding source through anterior rhinoscopy after clot removal. 1, 2

Immediate Triage Assessment

Life-threatening concerns take priority:

• Airway patency - Check for bleeding into the oropharynx or airway that could compromise breathing 1, 2
• Hemodynamic stability - Assess for signs of significant blood loss including tachycardia, syncope, orthostatic hypotension, or hemodynamic instability 1, 2
• Active bleeding severity - Determine if bleeding is minor versus massive 1, 2

Disposition based on initial assessment:

• Emergent hospital/ED evaluation required if airway compromise, hemodynamic instability, or signs of acute hypovolemia present 1, 2
• Prompt ambulatory evaluation appropriate for minor active bleeding without airway/hemodynamic issues, provided clinical expertise and supplies available 1, 2
• Routine office evaluation suitable when no active bleeding, prior bleeding was minor, and no concern for severe recurrence 1, 2

Critical History Elements to Document

Bleeding characteristics that predict severity:

• Duration >30 minutes over 24 hours indicates severe epistaxis requiring prompt management 1, 2
• >3 recent episodes of nasal bleeding suggests need for specialist evaluation 1, 2
• Bilateral bleeding or bleeding from mouth indicates more severe hemorrhage 1
• History of hospitalization or prior blood transfusion for nosebleeds 1, 2

Medication history (critical for treatment decisions):

• Anticoagulants (warfarin, DOACs) - check INR if on warfarin; these patients require resorbable packing if intervention needed 1, 2, 3
• Antiplatelet agents (aspirin, clopidogrel) - document use as these patients also require resorbable packing 1, 2, 3

Comorbidities that increase risk:

• Hypertension, cardiovascular disease, anemia, bleeding disorders, liver disease, kidney disease 1, 2, 3
• These conditions warrant more aggressive evaluation and closer monitoring 1, 2

Additional risk factors:

• Prior nasal/sinus surgery 2, 3
• Nasal cannula oxygen or CPAP use 2, 3
• Intranasal medications or illicit drug use 2, 3
• Personal or family history of bleeding disorders 2, 3

Family history:

• Recurrent bilateral nosebleeds in patient or family members - assess for hereditary hemorrhagic telangiectasia (HHT) by checking for nasal and oral mucosal telangiectasias 1, 2, 3

Physical Examination

Systematic visualization to identify bleeding source:

Anterior rhinoscopy (essential first step):

• Perform after removing any blood clots to allow proper visualization 1, 2, 3
• Examine the nasal septum, particularly Kiesselbach's plexus/Little's area where most anterior bleeds originate 2, 4, 5
• Use nasal speculum and good light source (headlamp preferred) 4

Nasal endoscopy (when indicated):

• Perform or refer for endoscopy when bleeding is difficult to control 1, 2
• When concern exists for unrecognized pathology (tumors, vascular malformations) 1, 2
• When anterior rhinoscopy fails to identify the bleeding source 2, 3
• For persistent unilateral epistaxis to examine posterior bleeding sources 3

Signs of hemodynamic compromise:

• Tachycardia, pallor, altered mental status, orthostatic vital sign changes 1, 2, 3

Laboratory Testing (Not Routine)

Reserve laboratory workup for specific clinical scenarios:

Complete blood count (CBC):

• Obtain in patients with frequent/profuse bleeding to assess for anemia and quantify blood loss severity 2
• Hemoglobin drop ≥2 g/dL indicates major bleeding requiring aggressive management 2

Coagulation studies (PT/INR, aPTT):

• Obtain in all patients on anticoagulation 2
• Check in patients with clinically relevant bleeding or suspected bleeding disorders 2

Do NOT obtain routine labs in patients with minor, self-limited epistaxis without risk factors 2

Documentation Requirements

The American Academy of Otolaryngology-Head and Neck Surgery mandates documenting:

• Bleeding duration, frequency, and estimated volume 1, 2
• Anticoagulation/antiplatelet medication use 1, 2
• Comorbid conditions 1, 2
• Prior treatments attempted and their effectiveness 1, 2
• Factors that increase bleeding frequency or severity 1, 2
• Outcome of intervention within 30 days or document transition of care 1, 2

Critical Pitfalls to Avoid

Do NOT skip clot removal before visualization - this prevents accurate identification of the bleeding source 2

Do NOT use non-resorbable packing in patients with bleeding disorders or on anticoagulation - use resorbable materials instead 1, 2

Do NOT aggressively lower blood pressure acutely - routine acute blood pressure lowering is NOT recommended during active epistaxis, as excessive reduction can cause or worsen renal, cerebral, or coronary ischemia, particularly in elderly patients with chronic hypertension 3

Do NOT overlook anticoagulation status - check INR if on warfarin and consider reversal for severe refractory bleeding 3

Monitor blood pressure but base control decisions on bleeding severity, inability to control bleeding, individual comorbidities, and risks of blood pressure reduction 3