›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
›Posterior bleed pathway if suspected
›Balloon posterior pack or posterior packing device
›Early ENT and anesthesia notification
›ICU-level monitoring consideration
›Trauma-specific red flags
›Expanding facial hematoma
›Emergent airway planning
›CTA head/neck consideration for vascular injury
›Clear rhinorrhea
›CSF leak concern
›Avoid packing through cribriform concern until imaging
›Periorbital ecchymosis or diplopia
›Orbital fracture concern
›CT maxillofacial priority
›Malocclusion or trismus
›Mandible fracture concern
›CT face or panorex per local pathway
›Monitoring and access
›Two large-bore IV access if significant bleeding concern
›Cardiac monitoring if posterior packing, hypoxia risk, or significant comorbidity
›Continuous pulse oximetry for ongoing bleeding or sedation
›Frequent reassessment for rebleed after interventions
Hemodynamic targets and resuscitation
›Perfusion goals
›MAP adequate for mentation and end-organ perfusion
›Avoid permissive hypotension only within major trauma protocol and without TBI concern
›Transfusion approach
›Type and screen for moderate bleeding concern
›Type and crossmatch for severe bleeding or posterior bleed
›Balanced component therapy if massive hemorrhage suspected
›Coagulopathy correction
›Anticoagulant reversal pathway activation if life-threatening bleed (Class I)
›Platelet threshold consideration if thrombocytopenia with ongoing bleeding