Tests to be done after a rta followed by a nose bleed
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investigations after road traffic accident trauma assessment
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epistaxis nosebleed after head trauma investigations
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Here is a comprehensive breakdown of the investigations that should be performed after a road traffic accident (RTA) followed by a nosebleed (epistaxis):
Context
A nosebleed following an RTA is a red flag. It may represent:
- Anterior nasal mucosal trauma (minor, most common)
- Skull base / cribriform plate fracture — especially basal skull fracture
- Nasal bone fracture
- Midface / Le Fort fracture
- Nasopharyngeal injury
- Coagulopathy secondary to massive trauma/haemorrhage
The workup follows ATLS (Advanced Trauma Life Support) principles and is tailored to the mechanism and associated findings.
Investigations
1. Primary Survey — Immediate Bedside Assessments
| Investigation | Purpose |
|---|---|
| SpO2 / Pulse oximetry | Airway compromise from blood aspiration |
| ECG | Cardiac contusion, arrhythmia |
| Blood pressure + HR | Haemodynamic instability from blood loss |
| Glasgow Coma Scale (GCS) | Detect intracranial injury |
| Pupil assessment | Herniation / CN III palsy |
2. Bloods (Laboratory Investigations)
| Test | Rationale |
|---|---|
| Full Blood Count (FBC/CBC) | Haemorrhage assessment, thrombocytopenia |
| Coagulation profile (PT, APTT, INR, fibrinogen) | Traumatic coagulopathy, DIC |
| Group & Screen / Crossmatch | Anticipate transfusion need |
| Urea & Electrolytes (U&E) | Baseline renal function |
| Liver Function Tests (LFTs) | Concurrent hepatic injury |
| Blood glucose | Altered consciousness workup |
| Arterial Blood Gas (ABG) | Oxygenation, acid-base status, lactate |
| Blood alcohol / Toxicology screen | If reduced consciousness or RTA context |
| Type and crossmatch | If haemodynamically unstable |
3. Imaging — Critical in This Scenario
A. Head & Face CT (Non-contrast)
- Most important investigation given RTA + epistaxis
- Identifies:
- Basal skull fracture (anterior cranial fossa, cribriform plate)
- Intracranial haemorrhage (extradural, subdural, subarachnoid, intracerebral)
- Nasal bone fracture
- Orbital blowout fracture
- Le Fort I / II / III midface fractures
- Sinus fractures (ethmoid, sphenoid — haemosinus)
- Traumatic subarachnoid haemorrhage
Key signs of basal skull fracture (clinical) that support urgent CT:
- Periorbital haematoma ("Raccoon eyes / Panda eyes")
- Mastoid bruising (Battle's sign)
- Haemotympanum
- CSF rhinorrhoea (clear fluid mixed with blood from nose — a "double ring" / halo sign on filter paper)
- CN VI / VII palsy
B. CT Cervical Spine
- Mandatory after high-velocity RTA — cervical injury must be excluded before clearing the airway and neck
C. Chest X-Ray / CT Chest
- Pneumothorax, haemothorax, aortic injury, rib fractures
D. FAST Ultrasound (Focused Assessment with Sonography in Trauma)
- Rapid bedside assessment for intraabdominal / pericardial haemorrhage
E. CT Abdomen & Pelvis (if haemodynamically stable)
- Solid organ injuries, retroperitoneal haemorrhage
F. CT Angiography (CTA)
- If severe/persistent epistaxis not responding to packing → suspected vascular injury (e.g., internal maxillary artery, anterior/posterior ethmoidal artery, carotid-cavernous fistula)
4. Special Investigations
| Test | Indication |
|---|---|
| Beta-2 transferrin assay (nasal fluid) | Confirm CSF rhinorrhoea if suspected |
| CT cisternography / MRI | Localise CSF leak if confirmed |
| Nasoendoscopy (ENT) | Direct visualisation of bleeding source; posterior epistaxis |
| Digital Subtraction Angiography (DSA) | If CTA shows vascular injury; facilitates embolisation |
Summary Algorithm
RTA + Epistaxis
↓
ATLS Primary Survey (Airway, Breathing, Circulation, GCS)
↓
Bloods: FBC, coag, G&S, ABG, metabolic panel
↓
CT Head + Face → Rule out skull fracture, ICH, midface fracture
CT C-spine → Mandatory in high-velocity RTA
CXR + FAST → Concurrent trauma assessment
↓
Is there CSF rhinorrhoea? → Beta-2 transferrin + CT cisternogram/MRI
Is there persistent/severe epistaxis? → ENT consult ± nasoendoscopy ± CTA ± embolisation
Key point: Epistaxis after an RTA should never be dismissed as a simple nosebleed. Until a basal skull fracture, CSF leak, and significant vascular injury are excluded, it requires urgent, systematic investigation.
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