Clinical Practice Guideline on Management of Nose Bleed (Epistaxis)

Nose bleed or Epistaxis is a common clinical condition that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people need medical attention for control of nose bleed.

Overall 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters are due to nasal bleed. Of this 6% of patient needs inpatient hospitalization for aggressive treatment of severe nose bleeds.

The American Academy of Otolaryngology, Head and Neck Surgery (AAOHNS) Foundation published the Clinical Practice Guidelines (CPG): for nose bleed (epistaxis) on 07th January 2020.

The target population for the guideline is any individual aged three years or older with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient’s quality of life (QOL).

This Clinical Practice Guideline (CPG) is intended for all clinicians who evaluate and treat patients with nose bleed. The purpose of this multidisciplinary CPG is to identify quality improvement opportunities in managing patients with nose bleeds and to create explicit and actionable recommendations to implement these opportunities in clinical practice.

With clear, actionable recommendations for clinical practice, the goals outlined in this CPG are to promote best practices, reduce unjustified variations in care of patients with nose bleed, improve health outcomes, and minimize the potential harms of nose bleed and/or interventions to treat nosebleed.

“This is the first multidisciplinary, evidence-based guideline on nosebleed developed in the United States,” said David E. Tunkel, MD, Chair of the guideline development group. “It informs clinicians about the current level of evidence and includes areas of improvement of practice – such as providing patient instructions for nasal packing care – that were developed by the guideline panel after a review of all the literature.”

The guideline authors are David E. Tunkel, MD; Samantha Anne, MD, MS; Spencer C. Payne, MD; Stacey L. Ishman, MD, MPH; Richard M. Rosenfeld, MD, MPH, MBA; Peter J. Abramson, MD; Jacqueline D. Alikhaani; Margo McKenna Benoit, MD; Rachel S. Bercovitz, MD, MS; Michael D. Brown, MD, MSc; Boris Chernobilsky, MD; David A. Feldstein, MD; Jesse M. Hackell, MD; Eric H. Holbrook, MD; Sarah M. Holdsworth, MSN, APRN; Kenneth W. Lin, MD, MPH; Meredith Merz Lind, MD; David M. Poetker, MD, MA; Charles A. Riley, MD; John S. Schneider, MD, MA; Michael D. Seidman, MD; Venu Vadlamudi, MD; Tulio A. Valdez, MD; Lorraine C. Nnacheta, MPH, DrPH; Taskin M. Monjur.

The guideline is endorsed by American College of Emergency Physicians (ACEP), American College of Radiology (ACR), American Rhinologic Society (ARS), American Society of Hematology (ASH), American Society of Pediatric Otolaryngology (ASPO), Cure Hereditary Hemorrhagic Telangiectasia (Cure HHT), Society of Interventional Radiology (SIR), Society of NeuroInterventional Surgery (SNIS), Society of Otorhinolaryngology and Head-Neck Nurses (SOHN), and The Triological Society. The American Geriatrics Society (AGS) provided an affirmation of value for the guideline.

CPG Action Statements for Nose bleed

The CPG recommends

1. At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not.
2. The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer.
3. (3a) For patients in whom bleeding precludes the identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing.
   (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications.
4. The clinician should educate the patient who undergoes nasal packing about the type of packing placed, the timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment.
5. The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use.
6. The clinician should perform anterior rhinoscopy to identify a source of bleeding after the removal of any blood clot (if present) for patients with nosebleeds.
7. (7a)The clinician should perform or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding.
8. The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents.
9. When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict the application of cautery only to the active or suspected site(s) of bleeding.
10. The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization.
11. In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, the reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications.
12. The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome.
13. The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care.
14. The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with non-resorbable packing, surgery, or arterial ligation/embolization.

Optional recommendations are given for

1. (7b) The clinician may perform or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is a concern for unrecognized pathology contributing to epistaxis.

References

1. Tunkel, D. E., Anne, S., Payne, S. C., Ishman, S. L., Rosenfeld, R. M., Abramson, P. J.,  Monjur, T. M. (2020). Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery, 162(1_suppl), S1–S38. https://doi.org/10.1177/0194599819890327