Patient with Active Epistaxis
Patient presents with nasal bleeding
All Pathways
OtolaryngologyEmergency
Epistaxis Management (AAO-HNSF 2020)
Epistaxis Management (AAO-HNSF 2020): Patient with Active Epistaxis → Hemodynamically Stable? → ⚠️ Resuscitate First → Apply Sustained Compression → Ble...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Decision Hemodynamically Stable?
Assess airway, breathing, circulation. Check for signs of significant blood loss: hypotension, tachycardia, pallor
03Warning ⚠️ Resuscitate First
IV access, fluids, type and cross. Consider blood transfusion. Apply bilateral anterior packing while stabilizing.
04Action Apply Sustained Compression
Pinch lower third of nose firmly for 5+ minutes continuously (KAS 2). Patient sitting forward, mouth breathing.
- Pinch soft cartilaginous portion (not bony bridge)
- Minimum 5 minutes uninterrupted
- Patient leans forward to prevent swallowing blood
05Decision Bleeding Stopped?
Release compression after 5 minutes. Check if bleeding has ceased.
06Action Document & Counsel
Document bleeding history, anticoagulant use (KAS 5). Counsel on prevention: humidification, nasal saline, avoid picking (KAS 13).
07Outcome Bleeding Controlled
Document outcome within 30 days (KAS 14). Arrange follow-up for packing removal if non-resorbable used.
08Action Anterior Rhinoscopy
After clot removal, perform anterior rhinoscopy to identify bleeding source (KAS 6). Use headlight, nasal speculum.
- Clear clots with suction
- Apply topical vasoconstrictor (oxymetazoline)
- Identify source: Kiesselbach plexus most common
09Decision Bleeding Source Identified?
Can you visualize an anterior bleeding point?
10Action Cauterize Bleeding Site
Apply topical anesthetic, then silver nitrate or electrocautery to active/suspected bleeding site only (KAS 9). Cauterize one side only to avoid septal perforation.
11Decision On Anticoagulation/Antiplatelet?
Is patient on warfarin, DOACs, aspirin, clopidogrel, or has bleeding disorder?
12Action Use Resorbable Packing
For patients on anticoagulation or with bleeding disorders, use resorbable packing materials (KAS 3b): Gelfoam, Surgicel, or FloSeal.
13Decision Bleeding Controlled with Packing?
Is bleeding adequately controlled after packing placement?
14Warning ⚠️ Escalate Care
Refer for surgical arterial ligation or endovascular embolization (KAS 10). Consider posterior packing as temporizing measure. ENT and IR consultation.
- Path rejoins step 07Shared downstream outcome
15Decision Recurrent Bilateral Bleeds?
Screen for nasal/oral telangiectasias and family history for hereditary hemorrhagic telangiectasia (KAS 12).
- Path rejoins step 07Shared downstream outcome
16Outcome Refer for HHT Workup
Refer to genetics/HHT center if Curaçao criteria met: epistaxis, telangiectasias, visceral AVMs, family history.
17Action Non-Resorbable Packing
Apply anterior nasal packing (KAS 3a): Merocel, Rapid Rhino, or ribbon gauze. Educate patient on packing care and removal timing (KAS 4).
- Typical removal: 24-48 hours
- Prophylactic antibiotics controversial
- Return precautions: fever, worsening pain
- Path rejoins step 13Shared downstream outcome
18Action Nasal Endoscopy
Perform nasal endoscopy to locate posterior or obscured bleeding sites (KAS 7a). Required for recurrent or unilateral epistaxis despite prior treatment.
- Path rejoins step 11Shared downstream outcome
- Path rejoins step 04Shared downstream outcome
Guideline Source
AAO-HNSF Clinical Practice Guideline: Nosebleed (Epistaxis)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address pediatric epistaxis management in detail
- Posterior packing techniques require ENT expertise
- Does not replace clinical judgment for hemodynamically unstable patients
- Anticoagulation reversal decisions require hematology input
Contraindicated Populations
none
Applicable Regions
USEUGlobal
US: Based on AAO-HNSF 2020 CPG
Global: May require adaptation to local resources
Version 1Next review: 2028-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Epistaxis Management (AAO-HNSF 2020)?
The Epistaxis Management (AAO-HNSF 2020) is a emergency clinical algorithm for Otolaryngology. It provides a structured decision tree to guide clinical decision-making, based on AAO-HNSF Clinical Practice Guideline: Nosebleed (Epistaxis).
What guideline is the Epistaxis Management (AAO-HNSF 2020) based on?
This algorithm is based on AAO-HNSF Clinical Practice Guideline: Nosebleed (Epistaxis) (DOI: 10.1177/0194599819890327).
What are the limitations of the Epistaxis Management (AAO-HNSF 2020)?
Known limitations include: Does not address pediatric epistaxis management in detail; Posterior packing techniques require ENT expertise; Does not replace clinical judgment for hemodynamically unstable patients; Anticoagulation reversal decisions require hematology input. Individual patient factors may require deviation from these recommendations.
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