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Nosebleed assessment and control

AAO-HNSF first aid, focused examination, packing and cautery principles, antithrombotic safety and referral for epistaxis in patients aged three years or older.

JurisdictionUnited States
Source check2026-08-20
Clinical reviewiatroX editorial team 路 Clinical editorial review 路 reviewed 2026-08-20 路 due 2027-08-20
AudienceUnited States healthcare professionals
This is an iatroX educational summary of named United States sources, not an official guideline. It does not replace the complete source documents, local policy, specialist advice or clinical judgement. Use the named authority, current FDA labeling, applicable state law, payer rules and local protocol where relevant.

Scope of this summary

Patients aged three years or older with active epistaxis or recurrent nosebleed who seek medical care, matching the AAO-HNSF guideline population. Major facial trauma, a known vascular tumor, bleeding after nasal or sinus surgery and very young children require separate pathways.
sources for this section:AAO-HNSF epistaxis 2020

The Bottom Line

  • For active anterior bleeding, have the patient sit forward and compress the soft lower third of the nose firmly and continuously for at least five minutes; do not repeatedly release pressure to check prematurely.
  • After initial control, remove clot when safe and perform anterior rhinoscopy to identify the bleeding site and look for a foreign body, mass, septal abnormality or other cause.
  • Use packing when bleeding prevents identification or persists despite compression. Choose resorbable packing for a patient with a suspected bleeding disorder or taking an anticoagulant or antiplatelet medicine.
  • When a site is identified, treat only that localized area with an appropriate intervention such as topical vasoconstrictor, moisturizing or lubricating therapy, or cautery after anesthesia; avoid indiscriminate bilateral septal injury.
  • Arrange nasal endoscopy or otolaryngology evaluation for recurrent bleeding despite prior packing or cautery, recurrent unilateral bleeding, or concern for an unrecognized pathology.
sources for this section:AAO-HNSF epistaxis 2020

Practical clinical workflow

1
Assess airway, breathing, circulation, hemodynamic status and estimated blood loss, then ask about duration, side, recurrence, trauma, nasal medicines or drug use, anticoagulants, antiplatelets and personal or family bleeding history.
2
Apply sustained soft-nose compression with suction available; use a topical vasoconstrictor when appropriate and not contraindicated, and establish intravenous access or laboratory testing when severity warrants it.
3
Inspect the anterior nose after clearing clot. If the site is visible, anesthetize and use one targeted treatment; if it cannot be seen and bleeding continues, pack with the patient鈥檚 bleeding risk and follow-up reliability in mind.
4
Give every packed patient written instructions covering the packing type, whether removal is needed, activity and medicine precautions, expected drainage and the symptoms that require urgent return.
5
For persistent or recurrent bleeding not controlled by packing or cautery, coordinate endoscopic arterial ligation or endovascular embolization assessment rather than repeating ineffective office procedures.
sources for this section:AAO-HNSF epistaxis 2020

Safety boundaries and escalation

  • Airway compromise, shock, ongoing brisk posterior bleeding, major anemia symptoms or inability to control bleeding requires emergency resuscitation and urgent specialist care.
  • In the absence of life-threatening bleeding, use first-line local control before reversing or withdrawing anticoagulant or antiplatelet therapy; coordinate any interruption with the prescribing indication and thrombosis risk.
  • Recurrent bilateral nosebleeds or a family history of recurrent bleeding should prompt assessment for hereditary hemorrhagic telangiectasia, including nasal or oral telangiectasia.
  • A unilateral mass, obstruction, cranial neuropathy or persistent unilateral bleeding must not be attributed to dryness without endoscopic or specialist evaluation.
sources for this section:AAO-HNSF epistaxis 2020

Localization

The AAO-HNSF guideline is a US multidisciplinary standard endorsed by emergency, hematology, pediatric and interventional societies. Local emergency, otolaryngology, transfusion and antithrombotic-reversal protocols still apply.
sources for this section:AAO-HNSF epistaxis 2020

Source documents

Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.

  1. American Academy of Otolaryngology鈥揌ead and Neck Surgery FoundationClinical Practice Guideline: Nosebleed (Epistaxis)Multidisciplinary clinical practice guideline for patients aged 3 years and older 路 published 2020-01-07 路 accessed 2026-08-20
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