New Epistaxis (Nosebleed) Management Practice Guidelines
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. List possible causes of epistaxis 2. Describe treatment options for anterior epistaxis
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from through , participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
The American Academy of Otolaryngology-Head and Neck Surgery Foundation has released new evidence-based guidelines on the management of epistaxis. Usually spontaneous and without obvious cause, it is estimated that nosebleeds will occur in ≥ 60% of individuals in the US and approximately 6% require care. Usual source is the nasal septum, although lateral walls are also vascular and may be a source.
Possible secondary causes that require specific management: Systemic diseases and head and neck disorders including
Tumors of the nose or nasopharynx
Vascular malformations of the head and neck
History of recent facial trauma
History of nasal and/or sinus surgery within the previous 30 days
Hemorrhagic telangiectasia syndrome (HHT)
Medications: e.g., anticoagulant or antiplatelet drugs
Anterior epistaxis is often manageable in the outpatient setting with the treatment plan described below | Can be visualizes with anterior rhinoscopy (nasal speculum) | 90% of epistaxis arises from anterior part of nasal septum
Posterior epistaxis is usually associated with brisk bleeding, may require acute hospital care | usually requires referral to specialist for endoscopy for visualization and treatment | Consider if bleeding not controlled with cautery or packing
Control acute bleeding
Prevent complications due to treatments
First line treatments
Moisturizing or lubricating agents
Nasal packing (resorbable and nonresorbable)
Nasal cautery (chemicals or electrocautery)
More complex management for minority of patients with refractory nosebleeds
Endoscopic arterial ligation
Treatment of Active Bleeding
Apply firm, sustained compression to the lower third of the nose for ≥5 minutes (minimum)
Topical vasoconstrictors can aid in decreasing the bleeding
0.05% oxymetazoline: Direct spray or soaked cotton
Epinephrine 1:1,000: soaked cotton (risk of systemic absorption and consequent tachycardia or elevated BP)
Perform anterior rhinoscopy to identify a source of bleeding after removing any blood clots (do not cauterize blindly)
Usually done using silver nitrate
Electrocautery is used for more severe cases
Cauterize first in a circular pattern around active site first before cauterizing active site
Moisturizing or lubricating agents may be helpful
If patient continues to have bleeding and source cannot be identified, apply nasal packing
Long duration for packing not advised | Time not specifically stated in the guidelines due to limited evidence | 48 hours reasonable and then reassess
Nasal packing (cotton stripping) impregnated with petrolatum (may come prepackaged) | Layer starting at floor of anterior nasal cavity (see AFP overview for more details in ‘Learn More – Primary Sources’ below)
Nasal tampons and nasal balloons also available
Some providers use antibiotics (oral or topical) but evidence is limited as to benefit
Patients at increased risk for bleeding due to medications
Use resorbable (i.e., absorbable, dissolvable) packing to avoid risk of bleeding that may occur upon removal of nonresorbable packing
Not necessary for patients taking low dose aspirin
Use the opportunity to identify risk factors for epistaxis including
Personal or family history that may indicate familial bleeding disorder
Intranasal drug use
Medications (anticoagulants, antiplatelet)
Recurrent bleeding (front line approaches not working)
Refer to specialist for nasal endoscopy to identify site and treat
May require surgical arterial ligation or endovascular embolization
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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