Clinical practice guidelines on Epistaxis released by AAO/HNSF
ALEXANDRIA, VA - The American Academy of Otolaryngology-Head and Neck Surgery Foundation published the Clinical Practice Guideline: Nosebleed (Epistaxis) in Otolaryngology-Head and Neck Surgery. This multidisciplinary, evidence-based guideline identifies quality improvement opportunities in the management of nosebleed and creates clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleed,
"Although it is common, methods of diagnosis and treatment for nosebleed have not been uniformly used across clinicians and settings. To address that and to help reduce variations in care, this guideline provides evidence-based recommendations to improve quality of care," said David E. Tunkel, MD, Chair of the guideline development group (GDG).
Care for nosebleed ranges from self-treatment and home remedies to more intensive, procedural intervention in medical offices, emergency departments, hospitals, and operating rooms. This clinical practice guideline is designed for patients who cannot manage their nosebleeds through self-treatment and instead have bleeding that is severe enough to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that affects a person's quality of life.
"This is the first multidisciplinary, evidence-based guideline on nosebleed developed in the United States," said Dr. Tunkel. "It informs clinicians about the current level of evidence and includes areas of improvement of practice - such as providing patient instructions for nasal packing care - that were developed by the guideline panel after a review of all the literature."
The guideline delineates clear and actionable recommendations to implement quality improvement opportunities in clinical practice. The GDG used evidence-based research from five clinical practice guidelines, 17 systematic reviews, 16 randomized controlled trials, and 203 related studies to inform the Key Action Statements (KASs) for patient care.
The target patient for the guideline is any individual who is three years old or older with a nosebleed or history of nosebleed who needs medical treatment or who seeks medical care. The target audience for the guideline includes all clinicians who evaluate and treat patients with nosebleed.
Key recommendations are-
(1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not.
(2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer.
(3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing.
(3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications.
(4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment.
(5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use.
(6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds.
(7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding.
(7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.
(8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include 1 or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents.
(9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding.
(10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization.
(11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications.
(12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome (HHT).
(13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care.
(14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization.
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