Step 1 of 8
Severity Grading & ABC Triage
Grade the bleed (1 mild → 4 life-threatening); assess airway, breathing and circulation; the unstable patient enters the emergency pathway
Epistaxis is graded by severity at the door because the grade drives the tempo of care. Grade 1 is a mild, self-limited anterior bleed; Grade 2 is moderate — recurrent or requiring intervention; Grade 3 is severe — requiring packing or causing a haemoglobin drop; and Grade 4 is life-threatening — with airway compromise or shock. The grade is assigned alongside an ABC assessment: the airway for patency, aspiration risk and oropharyngeal blood pooling (a compromised airway prompts oral intubation and emergency airway management); breathing for oxygen saturation and respiratory distress; and circulation for blood pressure, pulse, signs of shock and estimated blood loss.
The triage then resolves to a single decision — stable or unstable. The unstable patient — with hypotension, shock, massive haemorrhage or severe comorbidity — proceeds immediately to the emergency pathway. The stable patient proceeds to the standard evaluation of history, examination and pattern-based management. This stability decision is the chapter's first and most important fork: it ensures the exsanguinating posterior bleed is resuscitated and controlled before any leisurely diagnostic workup, while the common self-limited anterior bleed flows into the structured outpatient pathway.
- Grade 1 mild self-limited anterior; Grade 2 moderate recurrent or requiring intervention; Grade 3 severe packing or Hb drop; Grade 4 life-threatening airway/shock
- Airway — patency, aspiration risk, oropharyngeal pooling; compromise → oral intubation and emergency airway management
- Breathing — oxygen saturation, respiratory distress; Circulation — blood pressure, pulse, shock, estimated blood loss
- Unstable (hypotension, shock, massive haemorrhage, severe comorbidity) → emergency pathway; stable → standard evaluation
★ High-yield pearls (chapter-wide)
- Most anterior epistaxis originates from Kiesselbach's plexus on the anterior septum, while most severe posterior epistaxis arises from the sphenopalatine artery.
- Endoscopic sphenopalatine-artery ligation is the preferred definitive treatment for severe idiopathic posterior epistaxis, with a ninety to ninety-eight per cent success rate, and it is more cost-effective and better tolerated than prolonged packing.
- Anterior ethmoidal artery bleeding requires surgical ligation — it must never be embolised, because its connection to the ophthalmic circulation risks blindness.
- Recurrent unilateral epistaxis is a sinonasal malignancy until proven otherwise — it warrants endoscopy, biopsy and cross-sectional imaging.
- Delayed severe bleeding after endoscopic sinus or skull-base surgery, or after head trauma, should raise immediate concern for an internal-carotid-artery pseudoaneurysm — a limb- and life-threatening emergency evaluated by CT angiography and catheter angiography.
- An adolescent male with recurrent unilateral epistaxis and nasal obstruction has a juvenile nasopharyngeal angiofibroma until imaging proves otherwise — biopsy is avoided because of the bleeding risk.
- Hereditary haemorrhagic telangiectasia should be actively screened with the Curaçao criteria — recurrent epistaxis, mucocutaneous telangiectasia, visceral arteriovenous malformations and an affected first-degree relative — with three or more making the diagnosis definite.
- Topical tranexamic acid is a useful adjunct for anterior epistaxis, particularly in the anticoagulated patient and in recurrent bleeding.
- Packing is a temporising measure — surgery provides the highest long-term success rate, so a posterior bleed that persists despite a balloon should proceed to sphenopalatine-artery ligation rather than repeated packing.
- Diffuse bleeding from multiple sites points to a coagulopathy — correct the underlying disorder and avoid aggressive cautery, which only creates new bleeding points.
Evidence base
2 sources- HIGH
Tunkel DE, Anne S, Payne SC · Otolaryngol Head Neck Surg · 2020Practice guidelinePMID 31910111
AAO-HNS clinical practice guideline on nosebleed, covering initial assessment, severity, control and prevention.
- MOD
Krulewitz NA & Fix ML · Emerg Med Clin North Am · 2019ReviewPMID 30454778
Emergency-medicine review of epistaxis covering the ABC assessment and the stable-versus-unstable triage.
Decision tree
The unstable bleed exits to resuscitation, tamponade and angiography. The stable patient is localised by history and endoscopy, then managed by bleeding pattern — focal cautery, the coagulopathy work-up, or posterior sphenopalatine-artery ligation — with the malignancy, HHT and internal- carotid red flags branching off.