Epistaxis Control Procedure Note

Note Type: Epistaxis Control Procedure Note

Date/Time: [Procedure start time — end time]

Location: [ED / clinic / inpatient bedside / OR / other]

Clinician(s): [Performing clinician; assistants if applicable]

Procedure Summary

Epistaxis control—[left / right / bilateral / unable to determine] [anterior / posterior / unable to localize] [specific site if identified]; [compression / chemical cautery / electrical cautery / resorbable packing / nonresorbable packing / device: specify]; hemostasis [achieved / partial / not achieved]; complications [none / specify].

Indication and Suspected Source

[Indication: active epistaxis / recurrent epistaxis requiring procedural control]. [Severity: brisk/pulsatile vs slow ooze; hemodynamic concerns present/absent; airway concerns present/absent.] [Suspected bleeding source: anterior / posterior / unable to localize], [specific site if identified], [unilateral / bilateral]. (If source not visualized, explicitly state reason. Clearly distinguish suspected vs confirmed source.)

Hemorrhage Risk Modifiers

• Anticoagulant use: [agent / denies / unknown]; last dose: [timing / unknown]
• Antiplatelet use: [agent / denies / unknown]
• Bleeding disorder history: [specify / denies / unknown]
• Recent nasal trauma or procedures: [specify / denies / unknown]
• Medication history limitations: [none / specify limitation] (Include only if history incomplete; do not infer anticoagulant status.)

Pre-Procedure Assessment

• Vital signs: [BP], [HR], [RR], [SpO2]; [hemodynamically stable / unstable]
• Airway/breathing status: [no compromise / at risk / interventions required] (Include if bleeding heavy or posterior packing anticipated.)
• Anterior rhinoscopy: [performed / not performed]; clot removed prior to inspection [yes / no]
• Exam findings: [active bleeding point seen / no clear source identified], [laterality], [severity], [other notable findings]
• Labs: [Hgb], [Platelets], [INR] (Omit if no labs obtained.)

Consent

Consent obtained from [patient / surrogate / emergency exception invoked]. Discussed nature and purpose of procedure, material risks (pain, rebleeding, mucosal injury, septal perforation with cautery, packing discomfort, need for escalation), and alternatives. Questions answered; [patient / surrogate] agreed to proceed. (If emergency exception, document rationale.)

Time-Out

Time-out performed: patient identity verified, procedure verified, laterality confirmed. (Include only if performed per institutional policy. If not performed due to emergent circumstances, briefly document reason or omit section entirely.)

Procedure Details

(Document as chronological narrative.)

• Positioning: [seated / semi-upright / supine / reverse Trendelenburg]
• Topical agents:
  • Anesthetic: [agent and concentration], [application method], [dwell time]
  • Vasoconstrictor: [agent and concentration], [application method], [dwell time]
  • Hemostatic agent: [TXA or other agent, dose, method / none]
• Conservative measures: [sustained nasal compression with duration / suction and clot removal / vasoconstrictor trial / none]
• Visualization: [anterior rhinoscopy / nasal endoscopy / limited due to bleeding]
• Intervention:
  • Cautery: [chemical—silver nitrate / electrical], [site(s) with laterality]. Cautery limited to active/suspected bleeding site(s). (Include only if cautery performed.)
  • Packing: [resorbable / nonresorbable], [device name], [anterior / posterior], [laterality], [quantity/size], [balloon inflation volume if applicable]. (Include only if packing placed.)
  • Compression only: [duration and response]. (Include only if compression was definitive intervention.)
• Hemostasis outcome: [achieved / partial / not achieved]
• Observation period: [duration without rebleed / not performed]
• Escalation: [none / ENT consulted / transfer arranged / OR planned]

Findings

[Final description of bleeding site or inability to identify], [anterior vs posterior], [notable anatomy or pathology: septal deviation, suspected lesion, other]. EBL: [minimal / estimated volume if clinically significant]. (If source not identified, document exam performed, why localization was limited, and best-supported suspicion labeled as "suspected.")

Complications

[None / Complication: specify (pain out of proportion, vasovagal event, hypoxia, aspiration, mucosal trauma, persistent hemorrhage, other) and response taken]. (Always complete this section; use "None" if no complications.)

Post-Procedure Status

Patient [tolerated procedure well / tolerated with difficulty]. Repeat vitals [stable / specify if abnormal]. Bleeding status: [no active bleeding / controlled / ongoing]. Disposition: [discharge / admit / transfer]. [Monitoring plan if posterior packing placed.]

Aftercare and Follow-Up

Packing-specific aftercare (Include only if packing placed):

• Packing placed: [resorbable / nonresorbable], [device name]
• Removal plan: [not required—resorbable / to be removed by (who) at (location) in (timeframe)]
• Activity restrictions: Avoid nose blowing, straining, heavy lifting; sneeze with mouth open
• Nasal care: [saline spray / humidification / lubricating agents as applicable]
• Medications: [pain control approach], [OTC medications to avoid], [antibiotics if prescribed with rationale]

Return precautions (Always include):

• Recurrent bleeding not controlled with home measures
• Bleeding from mouth or throat suggesting posterior bleed
• Fever or increasing facial pain/swelling
• Shortness of breath
• Inability to tolerate packing or severe pain
• Syncope or significant lightheadedness

Follow-up: [ENT follow-up arranged for packing removal / recurrent bleeds / suspected lesion / not arranged—criteria for seeking ENT evaluation provided].

(Never omit laterality, intervention type, hemostasis outcome, or complications. Use "unable to determine" or "unknown" with documented limitation rather than leaving blank.)