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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