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ent.epistaxis.core.v1PRODUCTION
ent.epistaxis.core.v1

Epistaxis (anterior & posterior)

general_internal_medicineacutesubacuteadultpediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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.

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epistaxis scope confirmed; shock/reversal/HHT-management concerns flagged for routing

Patient inputs (15)

Warfarin vs dabigatran vs factor-Xa inhibitor vs antiplatelet determines whether/what reversal applies if bleeding becomes life-threatening; AAO-HNS KAS 11 = first-line measures BEFORE reversal/withdrawal (Tunkel 2020, PMID 31910111; Tomaselli ACC 2020, PMID 32680646)

Personal/family bleeding history (HHT, von Willebrand, thrombocytopenia, liver disease) changes packing choice (resorbable) and triggers the HHT screen (Tunkel AAO-HNS CPG 2020 KAS 3b/5/12, PMID 31910111)

Child = digital-trauma/dry-mucosa anterior bleed; adolescent male with unilateral obstructive epistaxis = juvenile nasopharyngeal angiofibroma until excluded (do NOT biopsy in ED) (Tunkel AAO-HNS CPG 2020, PMID 31910111)

Unilateral visualisable anterior (Kiesselbach) source vs bilateral / not-visualisable favours posterior — the dominant anterior-vs-posterior pivot (Tunkel AAO-HNS CPG 2020 KAS 6, PMID 31910111)

Brisk blood down the posterior pharynx despite firm anterior compression strongly raises a posterior (sphenopalatine) source and the airway/aspiration risk (Tunkel AAO-HNS CPG 2020 KAS 3a, PMID 31910122)

Failure of ≥5-10 min correctly applied firm compression to the lower (cartilaginous) third of the nose is the single most useful bedside posterior-source / escalation predictor (Tunkel AAO-HNS CPG 2020 KAS 2, PMID 31910111)

Tachycardia is an early hemorrhagic-shock marker in heavy posterior bleeding before hypotension appears (Tunkel AAO-HNS CPG 2020 KAS 1, PMID 31910122)

Hypotension / hypovolemia from severe posterior epistaxis → hemorrhagic-shock pathway; route OUT to the shock/transfusion engine (Tunkel 2020 KAS 1, PMID 31910111)

Airway compromise / aspiration of swallowed blood in massive posterior bleed is the life-threatening emergency this engine must screen first (Tunkel AAO-HNS CPG 2020 KAS 1, PMID 31910122)

Nasal endoscopy locates a non-visualisable/posterior source and screens for unilateral mass; contrast CT/MR for suspected JNA or tumour (do NOT biopsy a vascular nasopharyngeal mass) (Tunkel AAO-HNS CPG 2020 KAS 7a/7b, PMID 31910111)

Hypertension is associated with epistaxis presentation/severity but the AAO-HNS CPG gives limited guidance — control acutely if very high but do not delay hemostasis (Payne AAO-HNS HTN commentary 2020, PMID 31910123)

Baseline + serial Hb quantifies blood loss in heavy/posterior bleeding and sets transfusion threshold (Tunkel AAO-HNS CPG 2020 KAS 11, PMID 31910111)

INR on warfarin and a coagulation/platelet screen in suspected bleeding disorder guide reversal decision and packing type (Tunkel 2020 KAS 3b/5, PMID 31910111; Tomaselli ACC 2020, PMID 32680646)

Pregnancy-associated rhinitis/epistaxis is common; TXA is generally avoided routinely in pregnancy and renal-cleared (dose-adjust) — gating the adjunct (Joseph Cochrane 2018, PMID 30596479)

Tranexamic acid is renally cleared — dose-reduce in renal impairment when used as a topical/systemic adjunct (Joseph Cochrane 2018, PMID 30596479)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningmassive_posterior_bleed_airway_emergency
    Massive posterior epistaxis with airway compromise or aspiration of swallowed blood, bilateral brisk bleeding, inability to protect the airway (Tunkel AAO-HNS CPG 2020 KAS 1, PMID 31910122)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemorrhagic_shock_from_epistaxis
    Tachycardia progressing to hypotension, hypoperfusion, falling Hb from ongoing posterior bleed (Tunkel AAO-HNS CPG 2020 KAS 1/11, PMID 31910111)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereanticoagulant_associated_uncontrolled_epistaxis
    Epistaxis on warfarin/DOAC/antiplatelet that is uncontrolled by first-line measures or is life-threatening (Tunkel AAO-HNS CPG 2020 KAS 5/11, PMID 31910111; Tomaselli ACC 2020, PMID 32680646)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_adolescent_male_JNA_red_flag
    Adolescent male with unilateral epistaxis + progressive nasal obstruction ± a nasopharyngeal mass — juvenile nasopharyngeal angiofibroma until excluded (Tunkel AAO-HNS CPG 2020, PMID 31910111)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefailure_of_anterior_measures_posterior_source
    Bleeding continues despite correct compression + vasoconstrictor + cautery/anterior pack, bleeding from both nares, brisk posterior pharyngeal flow — posterior (sphenopalatine) source (Tunkel AAO-HNS CPG 2020, PMID 31910122)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehht_osler_weber_rendu_screen_positive
    Recurrent and/or bilateral epistaxis with mucocutaneous telangiectasia and/or family history of recurrent nosebleeds (Tunkel AAO-HNS CPG 2020 KAS 12, PMID 31910111; Faughnan HHT 2020, PMID 32894695)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_refractory_or_unilateral_mass_concern
    Recurrent unilateral bleeding despite prior packing/cautery, or a unilateral nasal mass — concern for tumour / posterior unrecognised pathology (Tunkel AAO-HNS CPG 2020 KAS 7a/7b, PMID 31910111)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Stepwise epistaxis control ladder (AAO-HNS 2020 KAS 2-11)
axis: epistaxis_control_ladderstep 1 - Step 1 — First aid: firm sustained compression (non-pharm)
Selected step "Step 1 — First aid: firm sustained compression (non-pharm)" — Any active anterior epistaxis at first contact
  • firm_sustained_compression_lower_third_nose_5-10min
    first line
    mechanical_hemostasis
    triggers: active_anterior_bleed
    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

ed playbook — drug actions (3)

  1. 1. topical oxymetazoline
    rxcui 7812
    0.05% 2-3 sprays • intranasal • once, repeat ×1
    trigger: Bleeding persists after firm compression (AAO-HNS KAS 8, PMID 31910111)
    Rapid mucosal vasoconstriction; improves visualisation for cautery
  2. 2. topical lidocaine (pre-cautery anaesthesia)
    rxcui 6387
    1-4% topical • intranasal • once before cautery
    trigger: Discrete anterior point visualised, cautery planned (KAS 9)
    Anaesthetise the single site before restricted cautery
  3. 3. topical tranexamic acid (adjunct)
    rxcui 10691
    500-1000 mg solution on pledget • intranasal_topical • once, 10-15 min dwell
    trigger: Diffuse oozing despite first aid — adjunct, NOT a packing substitute (mixed evidence, NoPAC negative — PMID 33612282)
    May reduce rebleed (Cochrane RR 0.71, PMID 30596479) but NoPAC found no packing benefit

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Active bleeding from the nostril / visible anterior (Kiesselbach) source — the common low-acuity presentation (Tunkel AAO-HNS CPG 2020 KAS 1-2, PMID 31910111); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Epistaxis (anterior & posterior)** (ent.epistaxis.core.v1).
Phenotype framing: 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).
Scope: 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.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Stepwise epistaxis control ladder (AAO-HNS 2020 KAS 2-11)** — step "Step 1 — First aid: firm sustained compression (non-pharm)".
1. firm_sustained_compression_lower_third_nose_5-10min (mechanical_hemostasis, first line) — 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

Setting playbook (ed) — Triage prompt-management need (KAS 1), run the control ladder (compression → vasoconstrictor → cautery → anterior pack → posterior pack/ENT), screen the airway/shock emergency, and do NOT reflexively reverse anticoagulation unless life-threatening (Tunkel AAO-HNS CPG 2020, PMID 31910111)
2. topical oxymetazoline 0.05% 2-3 sprays intranasal once, repeat ×1 — Bleeding persists after firm compression (AAO-HNS KAS 8, PMID 31910111) (Rapid mucosal vasoconstriction; improves visualisation for cautery)
3. topical lidocaine (pre-cautery anaesthesia) 1-4% topical intranasal once before cautery — Discrete anterior point visualised, cautery planned (KAS 9) (Anaesthetise the single site before restricted cautery)
4. topical tranexamic acid (adjunct) 500-1000 mg solution on pledget intranasal_topical once, 10-15 min dwell — Diffuse oozing despite first aid — adjunct, NOT a packing substitute (mixed evidence, NoPAC negative — PMID 33612282) (May reduce rebleed (Cochrane RR 0.71, PMID 30596479) but NoPAC found no packing benefit)

Non-pharmacologic actions:
- Firm sustained compression of the lower third of the nose ≥5-10 min (KAS 2)
- Anterior rhinoscopy after clot clearance to identify the source (KAS 6)
- Restricted chemical/electro-cautery of a single anterior point only (KAS 8/9)
- Anterior pack (resorbable if anticoagulated/bleeding disorder/HHT) (KAS 3a/3b)
- Posterior pack/balloon + ENT + admit for a posterior source (PMID 31910122)

AVOID / contraindication checks:
- Topical vasoconstrictor caution severe uncontrolled htn and coronary disease (AAO HNS KAS 8; Payne HTN commentary 2020, PMID 31910123)
- Restrict cautery to single active site avoid bilateral septal cautery perforation risk (AAO HNS KAS 9, PMID 31910111)
- Use resorbable packing if bleeding disorder anticoagulated or HHT (AAO HNS KAS 3b, PMID 31910111)
- First line measures BEFORE anticoagulant reversal or withdrawal unless life threatening (AAO HNS KAS 11, PMID 31910111)
- Tranexamic acid adjunct only not a packing substitute mixed evidence NoPAC negative (Reuben Ann Emerg Med 2021, PMID 33612282)
- Do not biopsy suspected juvenile nasopharyngeal angiofibroma in ED image first (AAO HNS CPG 2020, PMID 31910111)
- Tranexamic acid renal dose reduction and pregnancy gating (Joseph Cochrane 2018, PMID 30596479)

Monitoring

Regimen monitoring:
- rebleed pack displacement and airway check for posterior packs (AAO-HNS, PMID 31910122)
- serial Hb in heavy or posterior bleeding (AAO-HNS KAS 11, PMID 31910111)
- INR anticoagulation status if anticoagulated (Tomaselli ACC 2020, PMID 32680646)
- document outcome within 30d for nonresorbable pack surgery ligation embolization (AAO-HNS KAS 14, PMID 31910111)
- toxic-shock-precaution-with-prolonged-nonresorbable-packing (AAO-HNS CPG 2020, PMID 31910111)

Setting (ed) monitoring:
- Rebleed + pack displacement; airway/SpO2 if posterior pack (PMID 31910122)
- Serial Hb in heavy/posterior bleed (KAS 11)
- NEWS2/qSOFA trend for hemorrhagic-shock recognition

Follow-up plan: 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.
- Close-out criterion: prevention plan + secondary-cause referrals documented; anticoagulation resumption decision delegated

Monitoring phase: 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).

Disposition

Current setting: ed — Triage prompt-management need (KAS 1), run the control ladder (compression → vasoconstrictor → cautery → anterior pack → posterior pack/ENT), screen the airway/shock emergency, and do NOT reflexively reverse anticoagulation unless life-threatening (Tunkel AAO-HNS CPG 2020, PMID 31910111)

Disposition criteria:
- Anterior, controlled, non-resorbable pack → discharge + packing-care education + 24-72 h recheck (KAS 4/13)
- Posterior pack/balloon, instability, or significant anticoagulation → admit (ICU if airway/shock)
- Recurrent bilateral / telangiectasia / family history → HHT referral pathway (KAS 12; Faughnan 2020, PMID 32894695)

Escalation triggers (move to higher acuity):
- Airway compromise / hemodynamic instability → resuscitate + route OUT to id.sepsis.core.v1 (shock/transfusion analogue) (KAS 1)
- Failure of anterior measures / posterior source → posterior pack + ENT + admit (PMID 31910122)
- Life-threatening anticoagulant-associated bleed → route to heme.anticoagulation-management.core.v1 for reversal (KAS 11; Tomaselli ACC 2020, PMID 32680646)
- Refractory posterior bleed → endoscopic SPA ligation or embolization (KAS 10)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Massive posterior epistaxis with airway compromise or aspiration of swallowed blood, bilateral brisk bleeding, inability to protect the airway (Tunkel AAO-HNS CPG 2020 KAS 1, PMID 31910122)
- [LIFE_THREATENING] Tachycardia progressing to hypotension, hypoperfusion, falling Hb from ongoing posterior bleed (Tunkel AAO-HNS CPG 2020 KAS 1/11, PMID 31910111)
- [SEVERE] Epistaxis on warfarin/DOAC/antiplatelet that is uncontrolled by first-line measures or is life-threatening (Tunkel AAO-HNS CPG 2020 KAS 5/11, PMID 31910111; Tomaselli ACC 2020, PMID 32680646)

Citations

- 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) [PMID:31910111](https://pubmed.ncbi.nlm.nih.gov/31910111/)
- Cited evidence (PMID 31910122) [PMID:31910122](https://pubmed.ncbi.nlm.nih.gov/31910122/)
- Cited evidence (PMID 31910123) [PMID:31910123](https://pubmed.ncbi.nlm.nih.gov/31910123/)
- Cited evidence (PMID 33612282) [PMID:33612282](https://pubmed.ncbi.nlm.nih.gov/33612282/)
- Cited evidence (PMID 30596479) [PMID:30596479](https://pubmed.ncbi.nlm.nih.gov/30596479/)

Last reconciled with current guidelines: 2026-05-17.
References
  • 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) — PMID:31910111
  • Cited evidence (PMID 31910122) — PMID:31910122
  • Cited evidence (PMID 31910123) — PMID:31910123
  • Cited evidence (PMID 33612282) — PMID:33612282
  • Cited evidence (PMID 30596479) — PMID:30596479