Nosebleed (Epistaxis)

Nosebleed (Epistaxis)

(Affirmation of Value, April 2020)

The “Clinical Practice Guideline: Nosebleed (Epistaxis)” was developed by the American Academy of Otolaryngology-Head and Neck Surgery and affirmed of value by the American Academy of Family Physicians.  

Key Recommendations

• Individuals with a nosebleed who require prompt management should receive treatment for active bleeding 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. 
• Individuals in whom bleeding precludes identification of a bleeding site despite nasal compression should receive treatment for active bleeding with nasal packing. 
• Individuals with a suspected bleeding disorder or for individuals who are using anticoagulation or antiplatelet medications should receive resorbable packing to manage the nosebleed. Education should be provided about the type of packing placed, timing of, and plan for, removal of packing (if not resorbable), post-procedure care, and any signs or symptoms that would warrant prompt reassessment. 
• Anterior rhinoscopy should be performed to identify a source of bleeding after removal of any blood clot (if present) for individuals with nosebleeds. 
• Nasal endoscopy should be performed to identify the site of bleeding and guide further management for individuals with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. 
• Individuals with an identified site of bleeding should be treated with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents.
• Individuals with persistent or recurrent bleeding not controlled by packing or nasal cauterization should be evaluated for candidacy for surgical arterial ligation or endovascular embolization. 
• In the absence of life-threatening bleeding, first-line treatments should be used prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/ antiplatelet medications for patients using these medications. 
• Individuals with a history of recurrent bilateral nosebleeds or family history of nosebleeds should be assessed for 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. 
• Individuals with nosebleeds and their caregivers should receive education about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. 

The AAFP uses the category of “Affirmation of Value” to support clinical practice guidelines that provide valuable guidance, but do not meet our criteria for full endorsement. The primary reason for not endorsing this guideline included concerns about the use of expert opinion for many recommendations.