What tests should be performed on a patient presenting with fresh nose bleeding?

Laboratory and Diagnostic Testing for Acute Epistaxis

For a patient presenting with fresh nose bleeding, obtain a complete blood count (CBC) to assess for anemia and quantify blood loss severity, and check PT/INR and aPTT if the patient is on anticoagulation or has clinically significant bleeding. 1

Essential Laboratory Tests

Mandatory Testing

• CBC (Complete Blood Count): Required to assess for anemia and quantify blood loss severity, with a hemoglobin drop ≥2 g/dL indicating major bleeding requiring aggressive management 1
• Coagulation Studies: PT/INR and aPTT should be obtained in all patients on anticoagulation or with clinically relevant bleeding 1

Clinical Context for Testing

The decision to perform laboratory testing depends on the severity assessment. Testing is most critical when patients present with:

• Active bleeding with signs of hemodynamic instability 2
• Bleeding duration >30 minutes over 24 hours 2
• History of hospitalization or prior blood transfusion for epistaxis 1
• Bilateral bleeding or bleeding from the mouth (suggesting posterior source) 1

Physical Examination and Source Identification

Immediate Diagnostic Steps

• Remove blood clots by suction or gentle nose blowing to identify the bleeding source 1
• Anterior rhinoscopy: Perform to examine the nasal septum, as most nosebleeds originate from the anterior septum (Kiesselbach's plexus/Little's area) 1
• Nasal endoscopy: Must be performed or referred when bleeding is difficult to control, anterior rhinoscopy fails to identify the source, or there is concern for unrecognized pathology 1. Endoscopy localizes the bleeding site in 87-93% of cases 3

Critical History Documentation

Risk Factors to Document

The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting factors that increase bleeding frequency or severity 2:

• Personal or family history of bleeding disorders 2
• Anticoagulant or antiplatelet medication use 2, 1
• Intranasal drug use 2
• Prior nasal/sinus surgery 2
• Nasal trauma 2
• Nasal cannula oxygen or CPAP use 2
• Chronic kidney or liver disease 2
• Hypertension 2
• Cardiopulmonary disease 2
• Anemia 2

Special Diagnostic Considerations

Hereditary Hemorrhagic Telangiectasia (HHT) Screening

Assess for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds, as this may indicate HHT requiring specialized management 3

Common Pitfalls to Avoid

• Do not routinely order extensive coagulation panels for minor epistaxis in patients not on anticoagulation—focus testing on CBC and targeted coagulation studies based on clinical presentation 1
• Do not delay physical examination for laboratory results in stable patients—anterior rhinoscopy and source identification should occur immediately after initial stabilization 1
• Do not skip endoscopy when anterior rhinoscopy fails to identify the source or bleeding recurs despite treatment, as endoscopy identifies the source in the vast majority of cases 3, 1