12-phase flow (12)

1. 1FRAME
   Frame as a STEPWISE bleeding-control problem partitioned into the benign anterior (Kiesselbach) bleed vs the airway/hemorrhage-threatening posterior (sphenopalatine) bleed (Tunkel AAO-HNS CPG 2020, PMID 31910111). Hemorrhagic-shock resuscitation, definitive anticoagulation-reversal pharmacology, and HHT disease-modifying therapy are routed OUT by engine_id, not authored here.
   advance: epistaxis scope confirmed; shock/reversal/HHT-management concerns flagged for routing
2. 2ENTRY
   Distinguish the patient needing prompt management (active brisk bleed, both nares, posterior pharyngeal flow, hemodynamic change, anticoagulated) from the patient who does not, at first contact — AAO-HNS KAS 1 (Tunkel 2020, PMID 31910122)
   inputs: bleeding_laterality_and_site, posterior_pharyngeal_blood_flow
   actions: workup.epistaxis
   advance: prompt-management vs not triaged; laterality + posterior-flow recorded
3. 3CONTEXT
   Capture the bleeding-modifier set AAO-HNS KAS 5 mandates documenting: anticoagulant/antiplatelet identity, personal/family bleeding disorder & HHT features, hypertension, age (child digital-trauma vs adolescent-male JNA), intranasal drug/topical decongestant overuse (Tunkel 2020, PMID 31910111).
   inputs: anticoagulant_agent_identity, bleeding_disorder_or_family_history, hypertension_status, age_and_pediatric_vs_adolescent_male
   advance: bleeding modifiers + HHT/JNA screen documented
4. 4RED_FLAGS
   Screen the airway/hemorrhagic-shock emergency FIRST: airway compromise or aspiration of swallowed blood, hemodynamic instability (tachycardia → hypotension), massive ongoing posterior bleed. NEWS2/qSOFA aggregate the deterioration; positive → resuscitate airway + circulation and route OUT to id.sepsis.core.v1 (shock/transfusion analogue). AAO-HNS KAS 11 still applies: first-line measures before reversal in the ABSENCE of life-threatening bleeding.
   inputs: heart_rate, systolic_bp, spo2_and_airway_status
   actions: workup.airway_distress, calc.news2, calc.qsofa, protocol.septic_shock
   advance: airway secured + hemodynamics assessed; shock/airway emergency routed OUT if present
5. 5INITIAL_WORKUP
   AAO-HNS first-line: ≥5-10 min firm sustained compression of the lower (cartilaginous) third of the nose (KAS 2); clear clot and perform anterior rhinoscopy to identify the source (KAS 6); topical vasoconstrictor (oxymetazoline/phenylephrine) ± topical anaesthetic (KAS 8). CBC/Hb + INR/coag baseline if anticoagulated or heavy bleed (KAS 11). Compression response is the key escalation predictor.
   inputs: response_to_firm_compression, hemoglobin, inr_and_coagulation
   actions: panel.cbc, panel.coag, panel.cmp
   advance: compression + vasoconstrictor trialled; source seen or not; baseline labs sent if indicated
6. 6BRANCHING_WORKUP
   Anterior source identified → chemical (silver nitrate) or electro-cautery of the discrete site, restricted to the bleeding point, after anaesthesia (KAS 8/9). Source NOT identified or bleeding precludes it → anterior packing (resorbable if bleeding disorder/anticoagulated — KAS 3a/3b). Persisting/recurrent or unilateral → nasal endoscopy ± CT/MR for posterior source or mass (KAS 7a/7b); adolescent-male unilateral obstructive bleed → imaging for JNA (do NOT biopsy in ED).
   inputs: nasal_endoscopy_or_ct_for_mass
   actions: workup.epistaxis, workup.acute_headache, workup.lymphadenopathy
   advance: anterior source cauterised/packed OR posterior/mass pathway entered
7. 7DIFFERENTIAL
   Terminal differential with named pivots: anterior epistaxis (visualisable Kiesselbach source + controlled by anterior measures pivot) vs posterior epistaxis (failure of anterior measures + bilateral + posterior pharyngeal flow pivot) vs HHT (recurrent bilateral + mucocutaneous telangiectasia + family history pivot) vs anticoagulant-associated bleeding (drug + supratherapeutic INR pivot) vs unilateral nasal mass / JNA (adolescent male + unilateral obstruction + imaging pivot) vs hemoptysis / hematemesis (blood from below — coughed/vomited, not from the nose, pivot).
   advance: anterior-vs-posterior + secondary-cause differential resolved; look-alikes excluded
8. 8RISK_STRATIFICATION
   Stratify escalation risk: posterior source, anticoagulation, bleeding disorder, hemodynamic change, recurrent/refractory, and HHT raise the need for ENT, posterior packing/balloon, admission and possible endovascular/SPA ligation. HAS-BLED frames the bleeding-while-anticoagulated context for the resumption decision; NEWS2 aggregates physiologic risk.
   inputs: systolic_bp, heart_rate
   actions: calc.has_bled, calc.news2
   advance: escalation-risk tier + disposition trajectory assigned
9. 9TREATMENT
   Stepwise control ladder (AAO-HNS KAS 2-11): firm compression → topical vasoconstrictor → chemical/electrocautery of an identified anterior point → anterior packing → posterior pack/balloon (admit, ENT) → endoscopic SPA ligation or endovascular embolization for refractory bleeding (KAS 10). Tranexamic acid is an adjunct (mixed evidence — NoPAC negative, Cochrane/MA positive for rebleed). Anticoagulant-associated: first-line measures BEFORE reversal/withdrawal unless life-threatening (KAS 11) — life-threatening reversal decision routed to heme.anticoagulation-management.core.v1. HHT-specific: gentle resorbable packing, avoid cautery where possible.
   inputs: pregnancy, creatinine_renal_function, anticoagulant_agent_identity
   advance: bleeding controlled at the lowest effective ladder step; reversal/HHT/shock delegated by engine_id where indicated
10. 10DISPOSITION
    Anterior, controlled, non-resorbable pack → discharge with packing-care education + 24-72 h removal/recheck (KAS 4/13). Posterior pack/balloon, hemodynamic instability, ongoing bleed, significant anticoagulation, or post-ligation/embolization → admit (ENT/observation; ICU if airway/shock). Pseudo-epistaxis (hemoptysis/hematemesis) → route to the appropriate GI/pulmonary pathway.
    inputs: systolic_bp, spo2_and_airway_status
    advance: disposition documented; packing-care + return precautions given; non-nasal bleeding rerouted
11. 11MONITORING
    Packed/admitted: monitor for rebleed, pack displacement, hypoxia/airway (especially posterior packs — risk of hypoventilation), and toxic-shock features with non-resorbable packing; serial Hb in heavy bleed; INR/anticoagulation status. AAO-HNS KAS 14: document outcome within 30 days for non-resorbable pack / surgery / ligation / embolization (Tunkel 2020, PMID 31910111).
    inputs: hemoglobin, spo2_and_airway_status
    actions: panel.cbc
    advance: no rebleed / stable airway / Hb stable, OR re-escalation triggered
12. 12FOLLOWUP
    Prevention + secondary-cause closure: nasal mucosal humidification/emollient and digital-trauma avoidance (esp. children) (KAS 13); structured ENT follow-up for recurrent/posterior/cauterised/ligated cases; HHT genetic + multidisciplinary referral if screen positive (route to HHT pathway — Faughnan 2020, PMID 32894695); shared anticoagulation resumption-vs-hold decision (route to heme.anticoagulation-management.core.v1 — Tomaselli ACC 2020, PMID 32680646); imaging/ENT follow-up for any suspected JNA/tumour.
    inputs: recurrent_or_bilateral_epistaxis, anticoagulant_agent_identity
    advance: prevention plan + secondary-cause referrals documented; anticoagulation resumption decision delegated