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Abstract：
Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the great majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient\'s quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.
The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create 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 nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients.
The guideline development group made recommendations for the following key action statements: (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. (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. The policy level for the following recommendation about examination of the nasal cavity and nasopharynx using nasal endoscopy was an option: (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.
The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create 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 nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients.
The guideline development group made recommendations for the following key action statements: (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. (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. The policy level for the following recommendation about examination of the nasal cavity and nasopharynx using nasal endoscopy was an option: (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.
摘要：
流鼻血,也被称为鼻出血，是一个常见的问题，在美国至少60％的人中发生。虽然绝大多数流鼻血的严重程度和持续时间有限，大约6%的流鼻血的人会寻求医疗救助。就本准则而言，我们将鼻出血的目标患者定义为鼻孔出血的患者，鼻腔,或足以保证医疗建议或护理的鼻咽。这包括严重的出血，持久性,和/或复发，以及影响患者生活质量的出血。流鼻血的干预措施范围从自我治疗和家庭疗法到医疗办公室更密集的程序干预，急诊科,医院,和手术室。据估计，鼻出血占所有急诊科就诊的0.5％，占所有耳鼻喉科相关急诊科就诊的三分之一。据报道，0.2％的流鼻血患者因积极治疗严重流鼻血而住院。
本多学科指南的主要目的是确定流鼻血管理中的质量改进机会，并为在临床实践中实施这些机会制定明确可行的建议。本指南的具体目标是推广最佳做法，减少流鼻血患者护理中不合理的变化，改善健康结果，并将流鼻血或治疗流鼻血的干预措施的潜在危害降至最低。该指南的目标患者是任何年龄≥3岁、有鼻血或鼻血史、需要治疗或寻求医疗建议的个体。本指南的目标受众是评估和治疗鼻出血患者的临床医生。这包括初级保健提供者，如家庭医生，内科医生,儿科医生,医师助理,和执业护士。它还包括急诊医学提供者等专家，耳鼻喉科医师,介入放射科医师/神经放射科医师和神经介入医师，血液学家,和心脏病学家。本指南的设置包括鼻出血患者的任何评估和治疗部位，包括门诊医疗场所，急诊室,住院医院,甚至远程门诊遇到电话和远程医疗。鼻出血患者需要考虑的结果包括控制急性出血，预防反复发作的鼻出血，治疗方式的并发症，和诊断措施的准确性。本指南解决了诊断问题，治疗,预防流鼻血。它将重点关注通常通过电话给临床医生的流鼻血，办公室访问,和急诊室的遭遇。本指南讨论了一线治疗，如鼻腔压迫，血管收缩剂的应用，鼻腔填塞,还有鼻部烧灼.它还解决了更复杂的鼻出血管理，其中包括使用内窥镜动脉结扎和介入放射学程序。2个特殊组患者的管理选择，出血性毛细血管扩张综合征（HHT）患者和服用抑制凝血和/或血小板功能的药物的患者，包含在本指南中。本指南旨在关注工作组认为最重要的基于证据的质量改进机会。它不是一个全面的，管理鼻出血患者的一般指南。在这种情况下，目的是为临床医生定义有用的行动，通才,和来自不同学科的专家，以提高护理质量。相反，本指南中的陈述并不旨在限制或限制临床医生根据他们的经验和对个体患者的评估提供的治疗.
指南制定小组对以下关键行动声明提出了建议：（1）在初次联系时，临床医生应区分需要及时治疗的鼻出血患者和不需要及时治疗的患者。（2）临床医生应治疗需要及时治疗的患者的活动性出血，并持续用力压迫鼻子的下三分之一，有或没有病人或护理人员的帮助，5分钟或更长时间。（3a）对于尽管鼻部受压，出血仍无法识别出血部位的患者，临床医生应通过鼻腔填塞治疗持续活动性出血.（3b）临床医生应使用可吸收的包装，用于怀疑出血性疾病的患者或使用抗凝或抗血小板药物的患者。（4）临床医生应教育患者进行鼻腔填塞的类型，去除填料的时间和计划(如果不是可再吸收的)，术后护理,以及任何需要及时重新评估的体征或症状。（5）临床医生应记录增加任何鼻出血患者出血频率或严重程度的因素，包括个人或家族出血性疾病史，使用抗凝剂或抗血小板药物，或鼻内用药。(6)对于流鼻血的患者，临床医生应在清除任何血凝块（如果存在）后进行前鼻镜检查以确定出血源。(7a)临床医生应执行，或者应该指可以执行的临床医生，鼻内镜检查以确定出血部位，并指导复发性鼻出血患者的进一步治疗，尽管事先用包装或烧灼治疗，或复发性单侧鼻出血。（8）临床医生应通过适当的干预措施治疗已确定出血部位的患者，其中可能包括以下一种或多种：局部血管收缩剂，鼻烧灼,和保湿剂或润滑剂。(9)当选择鼻烧灼治疗时，临床医师应对出血部位进行麻醉,并将烧灼仅应用于活动或疑似出血部位.(10)临床医师应进行评估,或者是指可以评估的临床医生，对于未通过填塞或鼻腔烧灼术控制的持续性或复发性出血患者，可用于手术动脉结扎或血管内栓塞。(11)在没有危及生命的出血的情况下，临床医生应在输血前开始一线治疗，抗凝逆转,或停用抗凝/抗血小板药物的患者使用这些药物。(12)临床医生应评估，或者咨询可以评估的专家，有复发性双侧鼻出血史或有复发性鼻出血家族史的患者存在鼻毛细血管扩张症和/或口腔粘膜毛细血管扩张症，以诊断遗传性出血性毛细血管扩张综合征（HHT）。(13)临床医师应教育流鼻血患者及其照顾者流鼻血的预防措施,家庭治疗流鼻血，以及寻求额外医疗护理的迹象。（14）临床医生或指定人员应在30天内记录干预的结果，或记录使用不可吸收包装治疗的鼻出血患者的护理过渡，手术,或动脉结扎/栓塞。关于使用鼻内窥镜检查鼻腔和鼻咽检查的以下建议的政策水平是一种选择：（7b）临床医生可以执行，或者可以指可以执行的临床医生，鼻内窥镜检查，用于检查难以控制的鼻出血患者的鼻腔和鼻咽部，或担心导致鼻出血的未识别病理。
本多学科指南的主要目的是确定流鼻血管理中的质量改进机会，并为在临床实践中实施这些机会制定明确可行的建议。本指南的具体目标是推广最佳做法，减少流鼻血患者护理中不合理的变化，改善健康结果，并将流鼻血或治疗流鼻血的干预措施的潜在危害降至最低。该指南的目标患者是任何年龄≥3岁、有鼻血或鼻血史、需要治疗或寻求医疗建议的个体。本指南的目标受众是评估和治疗鼻出血患者的临床医生。这包括初级保健提供者，如家庭医生，内科医生,儿科医生,医师助理,和执业护士。它还包括急诊医学提供者等专家，耳鼻喉科医师,介入放射科医师/神经放射科医师和神经介入医师，血液学家,和心脏病学家。本指南的设置包括鼻出血患者的任何评估和治疗部位，包括门诊医疗场所，急诊室,住院医院,甚至远程门诊遇到电话和远程医疗。鼻出血患者需要考虑的结果包括控制急性出血，预防反复发作的鼻出血，治疗方式的并发症，和诊断措施的准确性。本指南解决了诊断问题，治疗,预防流鼻血。它将重点关注通常通过电话给临床医生的流鼻血，办公室访问,和急诊室的遭遇。本指南讨论了一线治疗，如鼻腔压迫，血管收缩剂的应用，鼻腔填塞,还有鼻部烧灼.它还解决了更复杂的鼻出血管理，其中包括使用内窥镜动脉结扎和介入放射学程序。2个特殊组患者的管理选择，出血性毛细血管扩张综合征（HHT）患者和服用抑制凝血和/或血小板功能的药物的患者，包含在本指南中。本指南旨在关注工作组认为最重要的基于证据的质量改进机会。它不是一个全面的，管理鼻出血患者的一般指南。在这种情况下，目的是为临床医生定义有用的行动，通才,和来自不同学科的专家，以提高护理质量。相反，本指南中的陈述并不旨在限制或限制临床医生根据他们的经验和对个体患者的评估提供的治疗.
指南制定小组对以下关键行动声明提出了建议：（1）在初次联系时，临床医生应区分需要及时治疗的鼻出血患者和不需要及时治疗的患者。（2）临床医生应治疗需要及时治疗的患者的活动性出血，并持续用力压迫鼻子的下三分之一，有或没有病人或护理人员的帮助，5分钟或更长时间。（3a）对于尽管鼻部受压，出血仍无法识别出血部位的患者，临床医生应通过鼻腔填塞治疗持续活动性出血.（3b）临床医生应使用可吸收的包装，用于怀疑出血性疾病的患者或使用抗凝或抗血小板药物的患者。（4）临床医生应教育患者进行鼻腔填塞的类型，去除填料的时间和计划(如果不是可再吸收的)，术后护理,以及任何需要及时重新评估的体征或症状。（5）临床医生应记录增加任何鼻出血患者出血频率或严重程度的因素，包括个人或家族出血性疾病史，使用抗凝剂或抗血小板药物，或鼻内用药。(6)对于流鼻血的患者，临床医生应在清除任何血凝块（如果存在）后进行前鼻镜检查以确定出血源。(7a)临床医生应执行，或者应该指可以执行的临床医生，鼻内镜检查以确定出血部位，并指导复发性鼻出血患者的进一步治疗，尽管事先用包装或烧灼治疗，或复发性单侧鼻出血。（8）临床医生应通过适当的干预措施治疗已确定出血部位的患者，其中可能包括以下一种或多种：局部血管收缩剂，鼻烧灼,和保湿剂或润滑剂。(9)当选择鼻烧灼治疗时，临床医师应对出血部位进行麻醉,并将烧灼仅应用于活动或疑似出血部位.(10)临床医师应进行评估,或者是指可以评估的临床医生，对于未通过填塞或鼻腔烧灼术控制的持续性或复发性出血患者，可用于手术动脉结扎或血管内栓塞。(11)在没有危及生命的出血的情况下，临床医生应在输血前开始一线治疗，抗凝逆转,或停用抗凝/抗血小板药物的患者使用这些药物。(12)临床医生应评估，或者咨询可以评估的专家，有复发性双侧鼻出血史或有复发性鼻出血家族史的患者存在鼻毛细血管扩张症和/或口腔粘膜毛细血管扩张症，以诊断遗传性出血性毛细血管扩张综合征（HHT）。(13)临床医师应教育流鼻血患者及其照顾者流鼻血的预防措施,家庭治疗流鼻血，以及寻求额外医疗护理的迹象。（14）临床医生或指定人员应在30天内记录干预的结果，或记录使用不可吸收包装治疗的鼻出血患者的护理过渡，手术,或动脉结扎/栓塞。关于使用鼻内窥镜检查鼻腔和鼻咽检查的以下建议的政策水平是一种选择：（7b）临床医生可以执行，或者可以指可以执行的临床医生，鼻内窥镜检查，用于检查难以控制的鼻出血患者的鼻腔和鼻咽部，或担心导致鼻出血的未识别病理。
