Epistaxis — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Anterior or posterior
   After first-aid compression — anterior or posterior? Airway status? (>90% anterior (Kiesselbach's plexus, mostly self-limited); posterior (sphenopalatine artery) is heavier/bilateral/draining into the throat with higher airway risk. Assess airway/vitals first (brisk posterior bleeding → airway risk). First aid: sit up and lean forward, continuously pinch the cartilaginous part of the nose (below the nasal bones) for 10–15 minutes without releasing + topical vasoconstrictor (oxymetazoline/epinephrine-soaked cotton).)
   • Posterior/still bleeding after anterior packing/airway involved → Posterior → balloon packing + admit
   • Anterior, localizable/self-limited → Anterior · cautery/packing
2. [End] Anterior · cautery/packing
   Anterior, localizable: first-aid compression is usually self-limiting; if it fails → after a topical vasoconstrictor, chemical cautery (silver nitrate, one side of the septum only, to prevent perforation) or anterior nasal packing (Merocel/Rapid Rhino), TXA may be used; for packed patients, prophylactic antibiotics, remove in 3–4 days (rare TSS). Control BP, correct anticoagulation/coagulopathy.
3. [End] Posterior → balloon packing + admit
   Posterior/still bleeding after anterior packing/bilateral throat drainage: posterior balloon or packing (or a Foley catheter, inflate 5–7 mL increasing to ≤15 mL) — very uncomfortable, needs analgesia ± sedation, ECG + pulse oximetry monitoring, admit, ENT consult; beware airway obstruction/soft palate necrosis/hypoxia. Refractory → sphenopalatine artery ligation/embolization. Control BP, correct anticoagulation.

Source guidelines & references

• Management of epistaxis (AAFP; MSD Manual; StatPearls)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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