What is the workup for epistaxis (nosebleed)?

From the Guidelines

The workup for epistaxis (nosebleed) should begin with a thorough history and physical examination, followed by stabilization of the patient with direct pressure to the anterior nasal septum for 10-15 minutes while the patient sits upright with slight forward head tilt, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The initial assessment should include determining if the bleeding is anterior (most common, 90%) or posterior, and inquiring about frequency, duration, severity, unilateral versus bilateral bleeding, trauma, medication use (especially anticoagulants like warfarin, DOACs, aspirin), and comorbidities like hypertension or coagulation disorders. Physical examination should include anterior rhinoscopy using a nasal speculum and adequate lighting to identify the bleeding site. Laboratory tests should include complete blood count, coagulation studies (PT/INR, PTT), and type and cross if significant blood loss is suspected. For persistent bleeding, consider nasal packing (anterior with Merocel or petroleum gauze; posterior with balloon catheters if needed), as suggested by the clinical practice guideline: nosebleed (epistaxis) executive summary 1. Refractory cases may require otolaryngology consultation for endoscopic evaluation, cauterization, or arterial ligation. Silver nitrate chemical cautery can be used for visible anterior bleeding vessels. Patients with recurrent epistaxis should be evaluated for underlying causes such as nasal dryness (treated with saline sprays and petroleum jelly), hereditary hemorrhagic telangiectasia, or tumors. Imaging studies like CT or MRI may be necessary if a mass or structural abnormality is suspected. Key considerations in management include the use of topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents, as well as the potential need for reversal of anticoagulation in patients taking these medications, as outlined in the clinical practice guideline: nosebleed (epistaxis) 1. Overall, the goal of the workup and management of epistaxis is to control the bleeding, prevent recurrence, and minimize complications, while also addressing any underlying conditions that may be contributing to the bleeding, as emphasized by the clinical practice guideline: nosebleed (epistaxis) executive summary 1. The most recent and highest quality study, the 2024 American Heart Association and American Red Cross guidelines for first aid 1, provides the foundation for the recommended approach to epistaxis management.

From the FDA Drug Label

Uses • temporarily relieves nasal congestion due to: • common cold • hay fever • upper respiratory allergies • temporarily relieves sinus congestion and pressure • shrinks swollen nasal membranes so you can breathe more freely

The answer to the question about work up for epistaxis is not directly addressed in the provided drug label for oxymetazoline (TOP) 2. Epistaxis, or nosebleed, is not mentioned in the label. Therefore, no conclusion can be drawn about the work up for epistaxis based on this information.

From the Research

Initial Assessment and Management

• Evaluation of a patient presenting with epistaxis should begin with assessment of vital signs, mental status, and airway patency 3
• Compressive therapy is the first step to controlling anterior epistaxis, with oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 as useful adjuncts 3, 4
• Directive nasal cautery, most commonly using silver nitrate, can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source 3, 4

Treatment Options

• Topical vasoconstrictors, direct pressure, cautery, tranexamic acid, nasal tampons, Foley catheters, or surgical intervention are management options for epistaxis 5
• Pharmacologic management with oxymetazoline may be adequate in the majority of patients with epistaxis, thus avoiding the need for nasal packing with its associated complications 4
• Nasal packing can be used if other methods are unsuccessful, but is often associated with pain and a risk of aspiration if it is dislodged 3

Disposition and Specialty Consultation

• Disposition is typically to home unless posterior epistaxis or significant comorbidities exist that warrant admission 5
• Specialty consultation may be pursued if interventions fail, particularly for posterior epistaxis or patients with significant comorbidities 3, 5

Risk Factors and Associated Conditions

• Risk factors for epistaxis include local trauma, foreign body insertion, substance abuse, neoplasms, inherited bleeding diatheses, or acquired coagulopathies 5
• Anticoagulant therapy is a main risk factor for epistaxis, with direct oral anticoagulants and vitamin K antagonists having comparable management and outcomes 6