Name: Epistaxis — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Most nosebleeds are anterior and stop with pressure — but a few are posterior airway/blood-loss emergencies or the first sign of something serious. The defensible chart documents the bleeding source, the blood loss, and the red flags (recurrent unilateral, a bleeding disorder, or a nosebleed in an infant).

01What's at stake

About 90% of bleeds are anterior (Kiesselbach plexus) and minor. The can't-miss minority: a posterior bleed (aspiration and significant occult blood loss), a juvenile nasopharyngeal angiofibroma behind recurrent unilateral bleeding in an adolescent boy, an underlying bleeding disorder/leukemia, and non-accidental trauma when an infant under 2 bleeds without trauma.

02Can't-miss differential

Posterior hemorrhage — airway/aspiration risk and major blood loss; usually needs admission.
Bleeding disorder / leukemia — recurrent (>5/yr), bilateral, or other mucosal bleeding; petechiae/bruising/organomegaly.
Juvenile nasopharyngeal angiofibroma — recurrent unilateral epistaxis ± obstruction in an adolescent male (may be invisible on anterior rhinoscopy).
Nasal foreign body — unilateral foul, bloody discharge (button battery = emergency).
Non-accidental trauma — atraumatic epistaxis in a child <2 is abnormal; HHT; anticoagulation/hemodynamic instability.

03History & exam

Recurrent unilateral bleeds in an adolescent boy? → angiofibroma (ENT)
>5 episodes/yr, bilateral, gum bleeding, bruising/petechiae, family history? → bleeding disorder/leukemia
Child <2 with atraumatic bleed? → consider NAT / systemic disease / foreign body
Anticoagulant/antiplatelet/NSAID use, liver disease? → coagulopathy
Tachycardia, hypotension, pallor? → significant blood loss
Clear clots, then visualize with a speculum + topical vasoconstrictor to find the source (anterior vs posterior).

Skip the typing

Work the case in the Epistaxis Workup — it records the bleeding source, anticoagulation status, and packing/observation, and assembles an MDM that documents the anterior-vs-posterior call and the can't-miss red flags.

04Management ladder

Clear clots → firm pressure on the cartilaginous alae (not the bony bridge), leaning forward, 5–15 min.
Topical vasoconstrictor (oxymetazoline) ± tranexamic acid; silver-nitrate cautery of a discrete site (never both sides of the septum).
Anterior packing (absorbable preferred for coagulopathy) — discharge with anti-staph antibiotics; watch for the nasal-cardiac (Kratschmer) reflex; bilateral packing can destabilize.
Posterior balloon/packing for posterior bleeds → admit (airway risk); ENT/IR for refractory bleeding (ligation/embolization).
Severe bleeding — ABCs, IV access, transfuse if symptomatic; reverse anticoagulation only for life-threatening/refractory bleeding (local measures first).

05What to document

▼ weak

"Nosebleed, stopped with pressure. Discharged with decongestant spray."

▲ defensible

"Recurrent right-sided epistaxis in a 15-year-old boy; hemodynamically stable. Anterior source not clearly seen — given recurrent unilateral pattern in an adolescent male, juvenile nasopharyngeal angiofibroma considered and ENT referral arranged. No bruising/petechiae or family bleeding history; not anticoagulated. Bleeding controlled with pressure and oxymetazoline. Counseled on pressure technique and moisturizer; ongoing decongestant spray not prescribed; return precautions given."

06Where charts fail

"Stopped with pressure, discharged" for recurrent unilateral bleeding in an adolescent boy (missed angiofibroma).
Not considering NAT/systemic disease for an atraumatic nosebleed in a child <2.
Missing the bleeding-disorder clues (recurrent/bilateral, petechiae, family history).
Reversing anticoagulation reflexively rather than using local measures first.
Not examining for a nasal foreign body, or not assessing for a septal hematoma after trauma.

07Sources

Bansal BB, Kambala S, Nesiama JA. Acute epistaxis: a comprehensive overview in the acute care setting. Pediatric Emergency Medicine Practice (EB Medicine). 2024;21(6).
Tunkel DE, Anne S, Payne SC, et al. Clinical practice guideline: nosebleed (epistaxis). Otolaryngol Head Neck Surg. 2020;162(1_suppl):S1-S38.
Joseph J, Martinez-Devesa P, Bellorini J, et al. Tranexamic acid for patients with nasal haemorrhage (epistaxis). Cochrane Database Syst Rev. 2018;(12):CD004328.
Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (NoPAC). Ann Emerg Med. 2021;77(6):631-640.

Epistaxis: documentation that holds up