What is the initial workup for a patient presenting with massive epistaxis (nosebleed)?

Initial Workup for Massive Epistaxis

For massive epistaxis, immediately assess airway patency and hemodynamic stability while simultaneously applying firm nasal compression, then obtain CBC to quantify blood loss, PT/INR and aPTT if the patient is anticoagulated, and perform anterior rhinoscopy followed by nasal endoscopy to identify the bleeding source. 1, 2

Immediate Triage and Stabilization

Massive epistaxis requires emergent evaluation in a hospital or emergency department setting when there is active bleeding with airway compromise, hemodynamic instability (tachycardia, syncope, orthostatic hypotension), or signs of significant blood loss. 1, 2

While assessing the patient's stability:

• Apply firm sustained compression to the lower third of the nose for at least 5-10 minutes without interruption, as this is the single most effective first-line intervention. 1, 3
• Position the patient seated with head tilted slightly forward to prevent blood from flowing into the airway or stomach. 3
• Treat ongoing active bleeding with nasal packing if compression fails. 1

Critical History Elements During Stabilization

While performing nasal compression, obtain these specific details that predict severity and guide management:

Bleeding characteristics:

• Duration >30 minutes over 24 hours indicates severe epistaxis requiring aggressive management. 1, 2
• Bilateral bleeding or bleeding from the mouth suggests posterior source. 1
• History of hospitalization or prior blood transfusion for epistaxis indicates high-risk patient. 1, 2

Medication history:

• Document all anticoagulants and antiplatelet agents, as these patients require resorbable packing materials only. 2, 3
• NSAIDs cause significant platelet dysfunction but should not be routinely discontinued unless bleeding cannot be controlled with local measures. 3

Comorbidities that increase risk:

• Hypertension, cardiovascular disease, renal disease (especially if requiring hemodialysis), liver disease, anemia, and bleeding disorders. 1, 2
• Personal or family history of bleeding disorders. 1, 2

Laboratory Testing

Laboratory workup is not routine but is essential in massive epistaxis:

• CBC is mandatory to assess for anemia and quantify blood loss severity; hemoglobin drop ≥2 g/dL indicates major bleeding requiring aggressive management. 2
• PT/INR and aPTT should be obtained in all patients on anticoagulation or with clinically relevant bleeding. 2
• Coagulation studies are indicated for patients with frequent/profuse bleeding or suspected bleeding disorders. 2

Physical Examination and Source Identification

After achieving temporary hemostasis with compression, systematic visualization is mandatory:

1. Remove blood clots by suction or gentle nose blowing, as this is essential for accurate source identification. 1, 2, 3

2. Perform anterior rhinoscopy to examine the nasal septum, as most nosebleeds originate from the anterior septum (Kiesselbach's plexus/Little's area). 1, 2

3. Nasal endoscopy must be performed or referred when:

   • Bleeding is difficult to control despite initial measures. 1, 2
   • Anterior rhinoscopy fails to identify the source. 1, 3
   • There is concern for unrecognized pathology (tumors, vascular malformations, pseudoaneurysm). 1, 2
   • Nasal endoscopy localizes the bleeding site in 87-93% of cases. 3

Critical pitfall: Never skip clot removal before attempting visualization, as this prevents accurate identification of the bleeding source. 2

Special Considerations for Massive Epistaxis

In cases of massive or recurrent epistaxis without obvious nasal pathology or coagulopathy, consider cavernous carotid aneurysm, especially in patients with history of trauma or in elderly patients. 4, 5, 6 This rare but life-threatening cause requires CT angiography for diagnosis. 4

For posterior epistaxis or bleeding refractory to initial measures:

• Posterior nasal packing with Foley catheter and tranexamic acid-soaked gauze may be necessary. 3
• Use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) in patients on anticoagulants to reduce trauma during removal. 2, 3

Documentation Requirements

Record these specific factors:

• Bleeding duration, frequency, and estimated volume. 2
• All anticoagulation/antiplatelet medications. 2
• Comorbid conditions. 2
• Prior treatments attempted and their effectiveness. 2
• Outcome of intervention within 30 days. 2

When to Escalate Treatment

If nasal packing fails or bleeding recurs, evaluate candidacy for surgical arterial ligation or endovascular embolization. 3 Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing, and endovascular embolization has an 80% success rate with recurrence rates <10% compared to 50% for nasal packing. 3