From the Guidelines
The workup for epistaxis should begin with a focused history and physical examination, including questions about duration, frequency, and severity of bleeding, trauma, medication use, and comorbidities like hypertension or bleeding disorders, as recommended by the 2020 clinical practice guideline on nosebleed (epistaxis) 1. The history should include onset, duration, and frequency of nosebleed, other sites of bleeding or bruising, current medical conditions, including hypertension, prior nasal or sinus surgery, nasal cannula oxygen, or CPAP use, to identify potential underlying causes of nosebleeds that will affect further workup and management 1. Vital signs should be measured, with particular attention to blood pressure, and the nose should be examined using adequate lighting and a nasal speculum to identify the bleeding site, which is anterior in 90% of cases (Kiesselbach's plexus) or posterior in more severe cases. Laboratory tests should include complete blood count to assess for anemia, coagulation studies (PT/INR, PTT) if on anticoagulants or suspected coagulopathy, and type and cross if significant blood loss has occurred. For recurrent or severe epistaxis, additional imaging like CT or MRI may be warranted to rule out masses or vascular abnormalities, as suggested by the 2020 clinical practice guideline on nosebleed (epistaxis) executive summary 1. Management typically begins with direct pressure by pinching the anterior nose for 10-15 minutes, followed by chemical cautery with silver nitrate or topical vasoconstrictors like oxymetazoline for anterior bleeds, and posterior bleeds may require nasal packing or balloon tamponade, and in severe cases, endovascular embolization or surgical ligation of feeding vessels may be necessary 1. Tranexamic acid (TXA) is an inexpensive antifibrinolytic agent that has been used to control acute nosebleeds, and studies have shown its effectiveness in reducing rebleed rates, although more research is needed to understand its indications and efficacy for nosebleed control 1. Addressing underlying causes like hypertension control or anticoagulant adjustment is essential for preventing recurrence, and the use of topical vasoconstrictors, cautery, and TXA can be effective in managing epistaxis, as supported by the 2020 clinical practice guideline on nosebleed (epistaxis) 1.
From the Research
Epistaxis Workup
Epistaxis, or nosebleed, is a common disorder that requires a thorough workup to determine the cause and appropriate treatment. The following steps are involved in the workup of epistaxis:
- Assessment of vital signs, mental status, and airway patency 2
- Examination of the nose using a nasal speculum and a good light source, such as a headlamp 2
- Evaluation of the patient's history, including any co-morbidities, intrinsic patient factors, and use of anticoagulant medication 3
- Coagulation screening, which is useful in patients on anticoagulant medication or with a history of bleeding diatheses 3, 4
Initial Assessment
The initial assessment of epistaxis patients commonly includes:
- First aid measures, such as compressive therapy and oxymetazoline nasal spray 2
- Observations, including monitoring of vital signs and airway patency 2
- Focused history taking, including questions about co-morbidities, medication use, and bleeding history 3
- Clinical examinations and investigations, such as nasal endoscopy and coagulation studies 2, 3
Diagnostic Considerations
When evaluating a patient with epistaxis, the following diagnostic considerations should be taken into account:
- Hypertension and anticoagulant use, which can adversely affect outcomes 3, 4
- Posterior bleeding, which may be associated with recurrent epistaxis and requires referral to otolaryngology or the emergency department for definitive treatment 2
- Inherited coagulopathies, such as von Willebrand disease, which may be present in patients with a personal or family history of bleeding tendency 4