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Epistaxis

This policy applies to: Patients whose chief complaint is severe or prolonged bleeding from the nose. 

Exclusion Criteria: Patients with respiratory compromise may first require airway control and mechanical ventilation. Patients with hemodynamic compromise may first require volume and blood product resuscitation.

Recognize

  • Severity of Bleeding
  • Airway patency 
  • Distress or Anxiety
  • Blood Thinners / Coagulopathies
  • Hemodynamic status
  • Facial trauma
  • Environmental factors

Evaluate

  • Medical History and Medications
  • Airway patency
  • Circulatory status
  • Bleeding disorders
  • Estimate Blood Loss
  • Pain

Administer Treatment

  • Patient positioning
    • Place patient in an upright sitting position with a forward lean to prevent ingestion or aspiration of blood. 
  • Apply direct pressure to the soft part of the nose.
  • Provide oral suctioning as needed.
  • Manage hypovolemia / shock as indicated.
  • Manage airway as indicated
  • Consider Zofran IV/IO for nausea associated with blood ingestion. Avoid PO administration. 
  • Consider analgesia. 
  • Consider mild sedation due to risk of increased bleeding from anxiety associate hypertension.
  • If bleeding unresolved via direct pressure consider nasal packing.
    • Prepare mixture of:
      • 1ml Epinephrine 1:1000
      • 1ml Lidocaine HCl 2%
    • For patients with Cardiovascular disease or uncontrolled hypertension:
      • Apply TXA as needed to soft rolled gauze or a commercial nasal packing device till wet.
      • Begin packing affected nares.
    • For all else:
      • Administer 1ml of mixture to each affected nare via nasal atomizer. Using gauze to prevent leaking after administration. 
      • Begin packing affected nares either with moistened soft rolled gauze or a commercial nasal packing device.
    • Consider IV/IO opioids for pain management. Avoid PO administration.

Consider Differentials

  • Facial Fractures
  • Uncontrolled Hypertension
  • Illicit drug use
  • Bleeding Disorders

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References

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Medications
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