01Approach to the Critical Patient/attcp59

Immediate priorities

›Primary survey and escalation triggers

›If airway threatened by ongoing hemorrhage

›Immediate suction

›Immediate airway positioning

›If persistent inability to protect airway, RSI with blood-contaminated airway plan

›Dual suction setup

›Video laryngoscopy first-line if available

›If hemodynamic instability or shock physiology

›Massive transfusion protocol activation per trauma criteria

›Blood products over crystalloid for suspected hemorrhagic shock

›TXA IV within trauma protocol window if major trauma with significant bleeding concern (Class I)

›If facial trauma with suspected basilar skull fracture

›No nasal instrumentation

›Early airway strategy and CT imaging priority

›Hemorrhage control sequence

›Direct pressure

›Continuous firm pressure to soft anterior nose for 10-15 minutes

›Lean forward posture

›Topical vasoconstrictor and anesthetic

›Oxymetazoline or xylometazoline topical

›Lidocaine with epinephrine topical if available

›Source localization once slowed

›Anterior bleeding focus versus posterior suspicion

›Foreign body or laceration concern

›Anterior measures first when safe

›Cautery if single visible anterior point and dry field

›Anterior packing if diffuse or not localized

02History/hx49

Mechanism and bleeding characterization

›Injury context

›Blunt facial trauma

›Penetrating nasal trauma

›High-energy mechanism

›Assault with repeated blows

›Fall with head strike

›Bleeding profile

›Onset time

›Continuous versus intermittent

›Estimated volume

›Posterior symptoms

›Blood in throat

›Hematemesis

›Coughing blood

›Laterality

›Unilateral

›Bilateral

›Prior control attempts

›Pressure duration and technique

›Prior packing or cautery

›Use of topical vasoconstrictors

Risk factors and comorbidities

›Medication exposures

›Anticoagulants (Z79.01)

›Warfarin

›DOAC

›Antiplatelets (Z79.02)

03Physical Exam/exam43

Focused airway, vitals, and bleeding localization

›Stability markers

›Mental status change

›Tachycardia

›Hypotension

›Orthostasis

›Hypoxia

›Airway and oropharynx

›Blood pooling in posterior pharynx

›Active bleeding down posterior pharyngeal wall

›Aspiration risk indicators

›Nasal exam basics

›External nasal deformity

›Septal deviation

›Visible anterior bleeding point

›Diffuse mucosal oozing

›Foreign body

›Laceration requiring repair

›Septal hematoma screening

›Boggy septal swelling

›Bilateral septal fullness

›Nasal obstruction out of proportion

›Signs of posterior epistaxis

›Bleeding without visible anterior source

›Persistent bleeding despite anterior measures

›Blood from both nares

›Significant blood in oropharynx

04Differential Diagnosis/ddx32

Life-threatening and trauma-associated causes

›Major arterial injury

›Internal carotid artery injury

›External carotid artery branch injury

›Traumatic pseudoaneurysm

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

›Cribriform plate involvement

›Associated CSF leak

›Midface fractures

›Le Fort fractures (S02.4-)

›Nasal bone fracture (S02.2)

›Septal fracture

›Septal hematoma or abscess (J34.0)

›Cartilage necrosis risk

›Orbital fracture with nasal bleeding (S02.3-)

›Trauma-related coagulopathy

›Dilutional coagulopathy

›Hypothermia-associated coagulopathy

›Acidosis-associated coagulopathy

Non-traumatic mimics or contributors

›Primary epistaxis (R04.0)

›Kiesselbach plexus bleeding

›Mucosal dryness

›Hypertensive urgency association

›Elevated BP as marker of stress rather than primary cause

›Inflammatory and infectious

›Acute rhinosinusitis

›Nasal vestibulitis

05Laboratory Tests/lt21

Hematology and coagulation

›Bleeding risk and anemia assessment

›Complete blood count for anemia and platelet count

›Hemoglobin trend if ongoing bleeding

›Platelet count threshold considerations

›<50 x 10^9/L with active bleeding supports transfusion consideration

›PT/INR for warfarin effect and liver dysfunction

›INR elevation supporting reversal in severe bleeding

›aPTT if heparin exposure suspected

›Anticoagulant-specific considerations

›Creatinine and eGFR for DOAC clearance context

›Reduced clearance increasing bleeding persistence risk

›Blood bank testing

›Type and screen for moderate bleeding concern

›Crossmatch if posterior packing or transfusion likely

›Group and save per local protocol

Point-of-care and adjunct tests

›Bedside testing

›Capillary glucose if altered mental status

›Venous blood gas if shock physiology

›Lactate mmol/L for hypoperfusion marker

›Pregnancy testing when relevant

›Urine or serum beta-hCG for imaging and medication decisions

06Diagnostic Tests/dt48

Scoring Systems

›Severity and monitoring tools

›Shock Index

›Heart rate divided by systolic blood pressure

›>0.9 supporting heightened hemorrhage concern

›Epistaxis Severity Score for suspected HHT

›Frequency

›Duration

›Intensity

›Anemia and transfusion history

›Trauma scores when multi-system trauma suspected

›Revised Trauma Score elements

›GCS trend relevance to imaging and airway decisions

MRI

›Limited acute role

›Persistent bleeding with concern for tumor or vascular malformation after stabilization

›MRI face/sinuses with contrast for soft tissue lesion characterization

›Suspected intracranial complication in selected cases

›MRI brain with contrast when CT non-diagnostic and neurologic deficits persist

›Constraints

›Time and access limitations in unstable bleeding

›Metallic foreign body contraindication assessment in penetrating trauma

CT

›CT maxillofacial without contrast

›Suspected facial fracture

›Nasal bone fracture

›Septal fracture

›Orbital floor fracture

07Disposition/dispo29

Level of care selection

›ICU or monitored setting

›Posterior packing in place

›Hypoxia risk

›Vagal events and bradycardia risk

›Rebleed risk requiring urgent escalation

›Ongoing transfusion requirement

›Significant comorbidity

›CAD

›Severe COPD

›OSA

›Inpatient admission

›Recurrent bleeding after ED control attempts

›Coagulopathy requiring reversal and observation

›Facial fracture requiring operative planning

›Septal hematoma requiring drainage and follow-up reliability concerns

›Transfer criteria

›Need for ENT endoscopic control not available locally

›Need for interventional radiology embolization capability

›Complex maxillofacial trauma requiring specialty coverage

Discharge criteria and follow-up

›Discharge suitability

›Bleeding controlled for observation period

›Normal vital signs and stable hemoglobin when checked

›No posterior packing

›No septal hematoma

›No high-risk fracture pattern requiring admission

›Follow-up timing

08Treatment/t98

First-line local control

›Mechanical measures

›Direct pressure technique

›Continuous compression of soft alae

›10-15 minute uninterrupted interval

›Adjunct cold application

›Ice pack to nasal bridge for vasoconstriction support

›Topical vasoconstrictors

›Oxymetazoline 0.05% intranasal

›2-3 sprays to affected nare

›Repeat once after 10 minutes if needed

›Avoid excessive repeated dosing in significant CAD or severe hypertension

›Xylometazoline intranasal

›Local equivalent dosing per product

›Topical anesthetic

›Lidocaine 4% topical

›Soaked pledgets for comfort and visualization

Tranexamic acid and hemostatic adjuncts

›Tranexamic acid topical

›TXA 500 mg in 5 mL applied to pledget or packing

›Placement at bleeding site for 10-15 minutes

›Repeat once if partial response

›Evidence notes

›Mixed RCT results across populations

›Reasonable adjunct when initial measures fail (ACEP Level C style consensus)

›Hemostatic packing materials

›Oxidized cellulose or gelatin-based sponges

›Adjunct for diffuse oozing

›Useful when anticoagulated

Cautery and anterior packing

›Chemical cautery

›Silver nitrate for single visible anterior source

›Avoid bilateral septal cautery in same session

›Risk of septal perforation

›Electrical cautery

›ENT-performed when available

›Anterior packing options

›Expandable nasal tampon

›Rehydration with saline

›Typical dwell time 24-48 hours per local protocol

›Inflatable anterior balloon device

›Lowest pressure to achieve hemostasis

›Pressure injury risk with overinflation

›Gauze ribbon packing with topical agent

›Requires experience

›Higher discomfort profile

Posterior epistaxis pathway

›Posterior bleeding suspicion triggers

›Persistent posterior pharyngeal blood

›Failure of anterior packing

›Large-volume bilateral bleeding

›Posterior packing devices

›Dual-balloon catheter

›Inflate posterior balloon to seat against choana

›Incremental inflation with patient tolerance monitoring

›Inflate anterior balloon to stabilize

›Minimal effective volume

›Secure catheter to prevent migration

›External fixation method per device

›Foley catheter technique if dedicated device unavailable

›Only with appropriate training and safety checks

›Avoid if skull base fracture concern

›Monitoring and supportive care

›Continuous pulse oximetry

›Anti-emetic to reduce retching and rebleed

›Ondansetron 4 mg PO/IV

›Repeat dosing per local protocol

›Analgesia

›Acetaminophen preferred

›Avoid NSAIDs when possible

›Definitive hemostasis escalation

›ENT endoscopic control

›Sphenopalatine artery ligation consideration

›Interventional radiology embolization

›Refractory posterior bleed

›Vascular injury suspicion without operative control

Infection prevention and medication considerations

›Antibiotics with packing

›Evidence uncertainty for routine prophylaxis

›Consider antibiotics for posterior packing or high-risk features (ACEP Level C style consensus)

›Immunocompromised state

›Valvular heart disease with specific risk discussion

›Prolonged packing duration

›Common regimens when chosen

›Amoxicillin-clavulanate PO

›Dosing per local formulary and renal function

›Clindamycin PO if penicillin allergy

›Dosing per local formulary

›Tetanus prophylaxis

›Open laceration or contaminated wound per immunization status

Anticoagulant and antiplatelet reversal

›Warfarin-associated severe bleeding

›4-factor PCC per local protocol (Class I)

›Weight-based dosing per INR category

›Vitamin K IV for sustained reversal (Class I)

›Typical 5-10 mg IV in severe bleeding scenarios

›Dabigatran-associated life-threatening bleeding

›Idarucizumab per local protocol (Class I)

›Factor Xa inhibitor-associated life-threatening bleeding

›Andexanet alfa where available per local protocol (Class IIa)

›4-factor PCC as alternative where andexanet unavailable (Class IIa)

›Antiplatelet-associated severe bleeding

›Platelet transfusion consideration in life-threatening bleeding with thrombocytopenia or platelet dysfunction (Class IIb)

›Desmopressin consideration for uremic platelet dysfunction (Class IIb)

09Special Populations/sp29

Pregnancy

›Maternal stabilization priority

›Airway and oxygenation focus with aspiration risk mitigation

›Left lateral tilt if hypotensive and viable gestation

›Medication considerations

›Topical oxymetazoline short-course generally acceptable when needed

›Avoid unnecessary systemic vasoconstrictors

›TXA use aligned with obstetric hemorrhage evidence when systemic therapy considered for major bleeding only

›Imaging considerations

›CT when clinically required for trauma

›Shielding and dose minimization principles

›Risk-benefit documentation

Geriatric

›Higher-risk features

›Anticoagulant and antiplatelet prevalence

›Frailty and aspiration vulnerability

›Lower physiologic reserve for blood loss

›Treatment nuances

›Lower tolerance for posterior packing

›Early ICU-level monitoring consideration

›Earlier laboratory assessment thresholds

›CBC and coagulation studies in most traumatic bleeds

Pediatrics

›Age-specific considerations

›Smaller nasal cavity limiting packing options

›Higher distress requiring supportive positioning and caregiver coaching

›Trauma red flags

›Non-accidental trauma consideration when inconsistent history

10Background/b27

Epidemiology

›General epistaxis context

›Epistaxis common across lifespan

›Anterior bleeds majority of cases

›Posterior bleeds less common and higher morbidity

›Trauma-associated patterns

›Nasal fracture common in facial trauma

›Septal hematoma uncommon but high consequence without drainage

Pathophysiology

›Anterior epistaxis

›Kiesselbach plexus vulnerability

›Mucosal disruption from trauma and dryness

›Posterior epistaxis

›Sphenopalatine artery branches involvement

›Higher flow and more difficult visualization

›Coagulopathy amplification

›Anticoagulation and platelet dysfunction prolonging mucosal bleeding

›Trauma-induced coagulopathy in severe injury

Therapeutic Considerations

›Stepwise escalation principle

›Pressure and topical vasoconstrictor first for most cases

›Cautery for localized anterior source

›Packing when not localized or persistent

›Posterior packing and specialty control for refractory or posterior bleeds

›Evidence framing for common interventions

›Cautery effective for focal anterior bleeds (Class I)

›Posterior packing requires monitored setting due to hypoxia and dysrhythmia risk (Class I)

›Topical TXA reasonable adjunct with mixed trial results (ACEP Level C style consensus)

11Patient Discharge Instructions/pdi22

Copy discharge instructions

›Nosebleed aftercare

›No nose blowing for 48-72 hours

›Sneeze with mouth open

›Avoid heavy lifting and straining for 48-72 hours

›Humidification at home

›Saline nasal spray several times daily

›Thin layer of petroleum-based ointment to anterior nares if dryness

›If bleeding returns

›Firm pressure to soft nose for 10-15 minutes without checking

›Topical oxymetazoline if advised and available

›If not controlled after 20-30 minutes, return to ED

›Return to ED immediately

›Trouble breathing

›Blood pouring into throat or vomiting blood

›Dizziness, fainting, chest pain, or shortness of breath

›Persistent bleeding despite pressure

›Severe headache, confusion, weakness, or vision changes after head injury

›Fever or worsening facial pain with packing in place

›Packing-specific instructions when applicable

›Do not remove packing unless instructed

›ENT follow-up for removal within advised timeframe

›Antibiotics only if prescribed

12References/r15

Clinical guidelines and consensus

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

›Key action statements on first-line measures, packing, and escalation

›Trauma references

›ATLS principles for airway and hemorrhage control in facial trauma

›Trauma society guidance for TXA use in major trauma hemorrhage

›Evidence grading notes used in this reference

›Class I: strong benefit and consensus for intervention in appropriate patients

›Class IIa: reasonable to perform, benefit likely exceeds risk

›Class IIb: may be considered, evidence weaker or benefit less well established

›ACEP Level C style consensus: limited evidence base, common ED practice supported by expert opinion

Evidence-based sources

›Systematic reviews and trials on topical tranexamic acid for epistaxis

›Mixed efficacy signals across RCTs and settings

›Reviews on posterior epistaxis definitive therapy

›Endoscopic sphenopalatine artery ligation outcomes

›Embolization outcomes and complication profiles

Evidence & Review

Evidence & Review