What tests should be done for a patient presenting with a fresh epistaxis (nosebleed)?

Diagnostic Testing for Acute Epistaxis

For a patient presenting with fresh epistaxis, laboratory testing is generally NOT required for most cases, as the diagnosis is clinical and management focuses on direct visualization and local control measures. 1

Initial Clinical Assessment (Not Laboratory Tests)

The primary "tests" for epistaxis are physical examination procedures, not blood work:

Essential Diagnostic Procedures

• Anterior rhinoscopy should be performed after removing any blood clots (by suction or gentle nose blowing) to identify the bleeding source 1
• Nasal endoscopy should be performed or referred for when:
  • Anterior rhinoscopy fails to identify the bleeding site 1, 2
  • Bleeding is difficult to control 1
  • There is concern for unrecognized pathology (tumors, foreign bodies) 1, 3
  • Recurrent epistaxis occurs despite prior treatment 2, 3
  • Nasal endoscopy localizes the bleeding site in 87-93% of cases 2

Severity Assessment (Clinical, Not Laboratory)

Assess for signs requiring urgent intervention (these are clinical observations, not lab tests):

• Hemodynamic instability: tachycardia, syncope, orthostatic hypotension 1, 4
• Bleeding duration >30 minutes over 24 hours 1
• Bilateral bleeding or bleeding from the mouth 1
• History of hospitalization or transfusion for prior epistaxis 1

When Laboratory Testing IS Indicated

Laboratory tests are only necessary in specific clinical scenarios:

History-Based Testing

While performing nasal compression, obtain history that may suggest need for additional testing 1:

• Coagulation studies (PT/INR, aPTT, platelet count) if:

  • Personal history of bleeding disorders (hemophilia, von Willebrand disease, thrombocytopenia) 3
  • Family history of bleeding disorders 1, 3
  • Patient reports bleeding from other sites 1
  • Currently on anticoagulants (warfarin, apixaban) or antiplatelet medications (aspirin, clopidogrel) 2, 3

• Complete blood count (CBC) if:

  • Signs of significant blood loss or anemia 1
  • Concern for thrombocytopenia 3
  • Potential need for blood transfusion 1

Screening for Hereditary Hemorrhagic Telangiectasia (HHT)

• Assess for nasal and oral mucosal telangiectasias (visual examination, not a lab test) in patients with:
  • Recurrent bilateral nosebleeds 1, 3, 4
  • Family history of recurrent nosebleeds 1, 3, 4
  • This is a clinical diagnosis based on examination findings 2, 3

Critical Pitfalls to Avoid

• Do not delay local control measures while waiting for laboratory results - compression, vasoconstrictors, and direct visualization take priority over blood work 1, 2
• Do not routinely order coagulation studies in patients with isolated, easily controlled epistaxis and no bleeding history 1
• Do not reverse anticoagulation or order emergent labs in hemodynamically stable patients whose bleeding is controlled with local measures 2

Summary Algorithm

For uncomplicated epistaxis: No laboratory testing needed - proceed directly to anterior rhinoscopy after clot removal 1

For severe or recurrent epistaxis: Consider CBC and coagulation studies only if there are risk factors (bleeding history, anticoagulation use, hemodynamic instability) 1, 3

For all cases: Nasal endoscopy is the most important "test" when anterior rhinoscopy is inadequate 1, 2