Epistaxis

Aka: Epistaxis, Nosebleed, Nasal bleeding

1. See Also
   1. Anterior Nasal Hemorrhage Management
   2. Posterior Nasal Hemorrhage Management
2. Pathophysiology
   1. See Nasal Anatomy
3. Signs and symptoms
   1. Nasal bleeding
      1. Unilateral or Bilateral nares
      2. Posterior pharynx
      3. Retrograde into lacrimal duct (rarely)
   2. Hypertension
      1. Often labile
      2. Not sustained
4. Causes
   1. Local (most common)
      1. Trauma
      2. Nose picking
      3. Dry air
      4. Irritants (e.g. Tobacco smoke, repeated Cocaine use)
      5. Topical medications (e.g. Intranasal Steroids)
      6. Nasal Foreign Body
      7. Forceful nose blowing
      8. Nasal surgery
      9. Intranasal polyp or neoplasm
   2. Systemic causes (uncommon)
      1. Bleeding Disorder
         1. See Bleeding Diathesis
         2. NSAIDs, Aspirin or anticoagulant use
      2. Hypertension (rarely causes Epistaxis)
5. Labs
   1. Indications (rare)
      1. Bleeding occurs from multiple sites in nose
      2. Signs of coagulopathy
   2. Tests
      1. Complete Blood Count with platelets
      2. Prothrombin Time
      3. Partial Thromboplastin Time
6. Management: Anterior Hemorrhage
   1. Bleeding sites
      1. Kiesselbach's Plexus at septum most common site
      2. Anterior end of inferior turbinate also common
   2. Position patient leaning forward
      1. Keeps blood from collecting posteriorly
      2. Prevents Nausea and airway obstruction
   3. Apply manual pressure for 5-20 minutes
      1. Squeeze nose to apply pressure to septum
   4. Decongest Nasal mucosa
      1. Insert with long forceps and leave in for 20 minutes
         1. Cocaine soaked 2x2 gauze rolled or
         2. Oxymetazoline (Afrin) on cotton pledget (or spray) or
         3. Lidocaine 2% and Phenylephrine 4% mix 1:1 on cotton
   5. Exam basics
      1. Use good lighting
      2. Have irrigant and suction (Frazier tip) available
      3. Use Eye Protection and mask
      4. Remove clot
   6. Localize and Cautery with Silver Nitrate
      1. Contraindications
         1. Bleeding source unclear
         2. Anticoagulant use (nasal pack instead, cautery unlikely to be effective)
      2. Apply to localized bleeding source for 30 seconds
      3. Avoid repeated cautery
         1. Risk of septal perforation
         2. Do not use on both sides of septum
      4. Silver nitrate is equivalent to electrocautery
         1. Toner (1990) J Laryngol Otol 104:617-8
   7. Bleeding continues
      1. See Nasal Packing
7. Management: Persistent bleeding
   1. See Anterior Nasal Hemorrhage Management
   2. See Posterior Nasal Hemorrhage Management
   3. Known coagulopathy
      1. Desmopressin Spray (DDAVP)
   4. Intractable Bleeding
      1. Arterial ligation
8. References
   1. Kucik (2005) Am Fam Physician 71:305-12
   2. Tan (1999) Med Clin North Am 83:43-56