Epistaxis Guidelines

Guidelines on coronavirus disease 2019 (COVID-19)

In May 2020, clinical recommendations out of Italy were published regarding the management of epistaxis during the coronavirus disease 2019 (COVID-19) pandemic. ^[19]

Personal protection recommendations include the following ^[19] :

• Disposable equipment use is strictly recommended
• FFP3 (Europe) or N99 (United States) masks are preferred, but if FFP3 masks are unavailable, FFP2 or N95 masks, covered by a surgical mask, can be used
• It is strongly recommended that health-care personnel employ cap and shoe covers, goggles, gowns, and double nitrile gloves

Clinical assessment recommendations include the following ^[19] :

• Nosebleed risk factors (ie, blood pressure, coagulation factors, ongoing therapies with antithrombotic or anticoagulant drugs) should be controlled
• The patient should be checked for fever, respiratory symptoms, and contacts at risk for COVID-19
• Investigate sudden loss of smell and/or taste
• If allowed, dress patients with a surgical mask
• Promptly assess the nosebleed’s severity
• It is recommended that noninvasive intervention (bidigital compression, administration of antifibrinolytic agents) be employed

Room setting recommendations include the following ^[19] :

• If conventional operating rooms are unavailable, employ well-demarcated areas within the emergency department complex
• The patient should be treated by a reduced and experienced clinical staff, including a surgeon and a scrub nurse, with proper personal protective equipment (PPE)

Treatment recommendations include the following ^[19] :

• Avoid unnecessary interventions
• If noninvasive procedures fail, nasal packing or cautery should be performed
• Resorbable packing, if available, is recommended
• If sphenopalatine artery ligation is needed for posterior epistaxis, the procedure should be postponed until COVID-19 testing has been performed
• Avoid using local anesthetic atomized sprays, employing soaked pledgets instead
• During the procedure, a suction system, within a closed system and employing a viral filter, should be used

Postprocedure recommendations include the following ^[19] :

• To reduce recurrence risk and optimize outcomes, the patient should receive postprocedural instructions on packing removal or antibiotic prophylaxis
• Carefully execute gowning and degowning procedures
• Standard PPE should be employed by personnel engaged in the decontamination of surgical equipment

AAO-HNSF guidelines

Guidelines on the management of epistaxis were published in 2020 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF). They include, but are not limited to, the following ^[34] :

• Upon initial contact, the clinician should determine whether a nosebleed patient does or does not require prompt management
• In patients who require prompt management, active bleeding should be treated with firm, sustained compression to the lower third of the nose, with or without the patient or caregiver’s help, for at least 5 minutes
• If, owing to bleeding, the bleeding site cannot be identified (despite nasal compression), nasal packing should be used to treat ongoing, active bleeding
• In patients with a suspected bleeding disorder or in those who are on anticoagulation or antiplatelet medications, resorbable packing should be used
• In any patient with a nosebleed, factors that lead to more frequent or severe bleeding, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use, should be documented
• In patients with nosebleeds, anterior rhinoscopy should be carried out to identify a bleeding source (although any blood clot, if present, should first be removed)
• To identify the bleeding site and guide further management in patients who, despite prior packing or cautery, have recurrent nasal bleeding, the clinician should either perform nasal endoscopy or make a referral to a clinician who can perform it; this should also be done in patients with recurrent unilateral nasal bleeding
• In patients whose epistaxis is difficult to control, as well as in those for whom concern exists that the epistaxis is associated with an unrecognized pathology, the clinician may examine the nasal cavity and nasopharynx with nasal endoscopy or make a referral to one who can
• Patients with an identified bleeding site should be treated with appropriate interventions; these may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents
• When employing nasal cautery, the bleeding site should be anesthetized, and the cautery should be restricted only to the active or suspected bleeding site(s)
• Patients in whom packing or nasal cauterization fails to control persistent or recurrent bleeding should be evaluated as candidates for surgical arterial ligation or endovascular embolization; the clinician should either perform the evaluation or make a referral to one who can
• If bleeding is not life-threatening, first-line treatments should be initiated before transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications from patients using these agents
• In patients with a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds, the clinician should assess, or make a referral to a specialist can assess, whether nasal telangiectasias and/or oral mucosal telangiectasias are present, in order to diagnose hereditary hemorrhagic telangiectasia (HHT) syndrome