This handout is for epistaxis (anterior & posterior). Your care team identified this based on: active bleeding from the nostril / visible anterior (kiesselbach) source — the common low-acuity presentation (tunkel aao-hns cpg 2020 kas 1-2, pmid 31910111).
Other reasons your team may use this plan: bleeding from both nares and/or blood running down the posterior pharynx, not controlled by anterior compression — posterior-source / airway-risk presentation (tunkel aao-hns cpg 2020 kas 3a, pmid 31910122); recurrent and/or bilateral nosebleeds, mucocutaneous telangiectasia, or family history of recurrent epistaxis — hht / osler-weber-rendu screen entry (tunkel aao-hns cpg 2020 kas 12, pmid 31910111; faughnan hht 2020, pmid 32894695); epistaxis on warfarin / doac / antiplatelet — anticoagulant-associated-bleeding entry (tunkel aao-hns cpg 2020 kas 5/11, pmid 31910111; tomaselli acc 2020, pmid 32680646).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| firm_sustained_compression_lower_third_nose_5-10min | — | — | — | AAO-HNS KAS 2 (Tunkel 2020, PMID 31910111) — pinch the soft cartilaginous lower third, head forward, ≥5-10 min continuous; controls the majority of anterior Kiesselbach bleeds without any drug or device |
Plan: Stepwise epistaxis control ladder (AAO-HNS 2020 KAS 2-11)
Call 911 or go to the nearest emergency room right away if you have:
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.
Guideline: AAO-HNS Clinical Practice Guideline: Nosebleed (Epistaxis) — Tunkel et al, Otolaryngol Head Neck Surg 2020;162(1_suppl):S1-S38 (PMID 31910111) + Executive Summary (PMID 31910122) — current dedicated nosebleed authority (no 2021-2026 AAO-HNS replacement). Supplemented by: NoPAC RCT (Reuben/Appelboam Ann Emerg Med 2021, PMID 33612282); Joseph Cochrane TXA-for-epistaxis 2018 (PMID 30596479); Hosseinialhashemi Ann Emerg Med 2022 (PMID 35752521) + Chiang network MA Acad Emerg Med 2023 (PMID 36757148); 2020 ACC Expert Consensus on Bleeding in Patients on Oral Anticoagulants (Tomaselli JACC 2020, PMID 32680646); Second International HHT Guidelines (Faughnan Ann Intern Med 2020, PMID 32894695); Payne AAO-HNS hypertension-and-epistaxis commentary 2020 (PMID 31910123)