Approach to the Critical Patient

Immediate priorities

Primary survey and escalation triggers

Hemorrhage control sequence

Trauma-specific red flags

Monitoring and access

Hemodynamic targets and resuscitation

Perfusion goals

Transfusion approach

Coagulopathy correction

History

Mechanism and bleeding characterization

Injury context

Bleeding profile

Prior control attempts

Risk factors and comorbidities

Medication exposures

Bleeding diathesis

Vascular and mucosal conditions

Prior epistaxis pattern

Associated symptoms suggesting alternate pathology

Physical Exam

Focused airway, vitals, and bleeding localization

Stability markers

Airway and oropharynx

Nasal exam basics

Septal hematoma screening

Signs of posterior epistaxis

Trauma survey of face and skull base

Facial bones and orbit

Mandible and dental

Skull base findings

Cervical spine considerations

Differential Diagnosis

Life-threatening and trauma-associated causes

Major arterial injury

Basilar skull fracture with nasal bleeding (S02.1-)

Midface fractures

Septal hematoma or abscess (J34.0)

Orbital fracture with nasal bleeding (S02.3-)

Trauma-related coagulopathy

Non-traumatic mimics or contributors

Primary epistaxis (R04.0)

Hypertensive urgency association

Inflammatory and infectious

Neoplasm

Systemic bleeding disorder

Laboratory Tests

Hematology and coagulation

Bleeding risk and anemia assessment

Anticoagulant-specific considerations

Blood bank testing

Point-of-care and adjunct tests

Bedside testing

Pregnancy testing when relevant

Diagnostic Tests

Scoring Systems

Severity and monitoring tools

MRI

Limited acute role

Constraints

CT

CT maxillofacial without contrast

CT head without contrast

CT angiography head/neck

Practical cautions

Ultrasound

Adjunct bedside applications

Limitations

Disposition

Level of care selection

ICU or monitored setting

Inpatient admission

Transfer criteria

Discharge criteria and follow-up

Discharge suitability

Follow-up timing

Treatment

First-line local control

Mechanical measures

Topical vasoconstrictors

Topical anesthetic

Tranexamic acid and hemostatic adjuncts

Tranexamic acid topical

Hemostatic packing materials

Cautery and anterior packing

Chemical cautery

Electrical cautery

Anterior packing options

Posterior epistaxis pathway

Posterior bleeding suspicion triggers

Posterior packing devices

Monitoring and supportive care

Definitive hemostasis escalation

Infection prevention and medication considerations

Antibiotics with packing

Tetanus prophylaxis

Anticoagulant and antiplatelet reversal

Warfarin-associated severe bleeding

Dabigatran-associated life-threatening bleeding

Factor Xa inhibitor-associated life-threatening bleeding

Antiplatelet-associated severe bleeding

Special Populations

Pregnancy

Maternal stabilization priority

Medication considerations

Imaging considerations

Geriatric

Higher-risk features

Treatment nuances

Pediatrics

Age-specific considerations

Trauma red flags

Management adjustments

Background

Epidemiology

General epistaxis context

Trauma-associated patterns

Pathophysiology

Anterior epistaxis

Posterior epistaxis

Coagulopathy amplification

Therapeutic Considerations

Stepwise escalation principle

Evidence framing for common interventions

Patient Discharge Instructions

Copy discharge instructions

Nosebleed aftercare

If bleeding returns

Return to ED immediately

Packing-specific instructions when applicable

References

Clinical guidelines and consensus

AAO-HNSF Clinical Practice Guideline: Nosebleed (Epistaxis), 2020 update

Trauma references

Evidence grading notes used in this reference

Evidence-based sources

Systematic reviews and trials on topical tranexamic acid for epistaxis

Reviews on posterior epistaxis definitive therapy