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Epistaxis

BASICS

DESCRIPTION

  • Bleeding from nares, nasal cavity, or nasopharynx involving anterior or posterior mucosa.
  • Intractable epistaxis: recurrent or persistent despite packing or multiple episodes needing medical care.
  • Synonym: nosebleed.

EPIDEMIOLOGY

  • Bimodal incidence: peaks in children <15 years and adults >50 years (especially 70-79).
  • Most common in males <49 years.
  • Rare in children <2 years.
  • ~6% require medical/surgical intervention; ~1 in 200 ER visits.
  • Lifetime prevalence ~60%.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Most nosebleeds due to local causes rather than systemic disease.
  • Anterior (90-95%): Kiesselbach plexus.
  • Posterior (5-10%): Woodruff plexus (sphenopalatine artery branches). May present with hematemesis or hemoptysis.

Local causes:

  • Trauma, nose picking (epistaxis digitorum).
  • Foreign bodies, septal perforation, fractures, surgery, barotrauma.
  • Local inflammation/infection (viral URI, sinusitis, TB, syphilis).
  • Irritant inhalation (smoking, cocaine, rhinitis).
  • Topical steroid/antihistamine overuse.
  • Nasal vasoconstrictor overuse.
  • Septal deviation, low humidity, oxygen, CPAP.
  • Tumors (benign/malignant), vascular malformations (e.g., post-trauma carotid aneurysm).

Systemic causes:

  • Thrombocytopenia, congenital/acquired coagulopathies.
  • Liver/renal disease, chronic alcohol abuse, leukemia.
  • Anticoagulant use, CHF.
  • Hereditary hemorrhagic telangiectasia (HHT).
  • Collagen disorders, mitral valve stenosis, multiple myeloma, polycythemia vera, HIV.

RISK FACTORS

  • Local irritation.
  • Medications: aspirin, clopidogrel, ginseng, garlic, ginkgo biloba, sildenafil, warfarin, other anticoagulants.
  • Prior septoplasty/turbinate surgery, anemia, thrombocytopenia increase recurrent risk.

GENERAL PREVENTION

  • Nighttime humidification.
  • Cut fingernails, avoid nose picking.
  • Spray nasal meds laterally, using opposite hand.
  • Use petroleum jelly to prevent mucosal drying.

COMMONLY ASSOCIATED CONDITIONS

  • Vascular malformations/telangiectasia (HHT).
  • Neoplasm (rare, suspect if persistent unilateral bleeding).
  • Systemic coagulopathy, cirrhosis, renal failure, alcohol misuse.
  • Hypertension not proven cause but may worsen bleeding control.

DIAGNOSIS

HISTORY

  • Assess anemia and cardiovascular compromise.
  • Determine side, severity, duration of bleeding.
  • Identify trauma (including nose picking), cocaine use.
  • Past episodes and frequency.
  • Comorbidities (cirrhosis, coagulopathies).
  • Medications: nasal sprays, anticoagulants, antiplatelets.
  • Symptoms of posterior bleeding (nausea, hematemesis, hemoptysis).

PHYSICAL EXAM

  • Airway patency and cardiovascular stability.
  • Localize bleeding site (anterior vs posterior).
  • Use nasal speculum and good light with patient upright/semi-upright.
  • Patient leans forward and pinches nose between exams.

DIFFERENTIAL DIAGNOSIS

  • Usually clear clinically.
  • Include posterior bleeding as differential in chronic blood loss.

DIAGNOSTIC TESTS

  • Labs/imaging not usually needed if bleeding controlled easily.

Initial tests

  • No labs for mild responsive cases.
  • For recurrent/intractable: CBC, PT/PTT, BMP, cross-match, toxicology if illicit nasal drugs suspected.

Follow-up and special tests

  • Evaluate neoplasia if recurrent unilateral bleeding.
  • Nasal endoscopy.

SPECIAL POPULATIONS

  • Pediatric: more likely anterior, idiopathic, recurrent.
  • Geriatric: more likely posterior bleeding.

TREATMENT

OUTPATIENT

  • Most cases managed outpatient.
  • Home treatment: Nosebleed QR powder (hydrophilic polymer + potassium salt) promotes scab.
  • Apply direct pressure (pinch nasal ala) 5-20 min without break stops most bleeds.
  • Clear clots by nose blowing.
  • Ice pack over nose dorsum aids hemostasis.
  • Inspect septum for bleeding site.

GENERAL MEASURES

  • Resuscitation as needed; ABC approach.

MEDICATION

First Line

  • Topical vasoconstrictors:
  • Oxymetazoline 0.05%
  • Phenylephrine 0.5-1%
  • Epinephrine 1:1000
  • Cocaine 4%

Second Line

  • Chemical (silver nitrate) or electrical cautery.
  • Nasal packing: ribbon gauze, nasal tampons, balloon catheters.
  • Refractory: surgical ligation, endoscopic ligation/cautery, endovascular embolization.

ISSUES FOR REFERRAL

  • Posterior bleeds often need ENT consult.
  • Anterior bleeds refractory to conservative, packing, cautery.
  • Recurrent epistaxis.
  • HHT patients require ENT follow-up.
  • Concurrent anticoagulation management:
  • Therapeutic INR with bleeding stop: continue same warfarin dose.
  • Supratherapeutic INR: manage accordingly.
  • Persistent bleeding: stop anticoagulants, give vitamin K, PCC as needed.
  • Novel anticoagulants: less epistaxis but harder to control when it occurs.

ADDITIONAL THERAPIES

  • Nasal packing with ribbon gauze or nasal tampons.
  • Routine systemic antibiotics unnecessary; topical may be effective and cheaper.
  • Floseal (thrombin gel): better tolerated, more effective than packing.
  • Local tranexamic acid reduces bleeding time versus anterior packing.
  • Silver nitrate cautery for active anterior septal bleeding (75% concentration preferred).
  • Limit cautery to one septal side; wait 4-6 weeks between treatments to prevent perforation.
  • Posterior packing with balloon devices (e.g., Foley catheter).
  • Hospital monitoring generally required for posterior packing.

SURGERY/OTHER PROCEDURES

Packing for anterior bleed

  • Vaseline ribbon gauze layering from floor upward.
  • Ends of ribbon gauze protrude outside nostril; secure with external gauze.
  • Nasal tampon lubricated with KY jelly or antibiotic ointment.
  • Merocel and Rapid Rhino packs easier and better tolerated.

Packing for posterior bleed

  • Foley catheter or specialized balloon inserted through nose to posterior oropharynx.
  • Balloon inflated (e.g., 10 mL saline), traction maintained with padded umbilical clamp.

ADMISSION AND NURSING CONSIDERATIONS

  • Hospitalize elderly, posterior bleeding, coagulopathy, or significant comorbidities.
  • Admission indications: posterior bleed, intractable vomiting, hemodynamic instability, clotting disorders.
  • Universal ABC approach; stop bleeding.

ONGOING CARE

FOLLOW-UP

  • Hemodynamic monitoring if severe blood loss.
  • Nasal packing left in place at least 24 hours (some recommend 3-5 days).
  • Rebleeds often occur 24-48 hours after removal.
  • Longer packing duration risks mucosal injury and toxic shock syndrome.

PATIENT EDUCATION

  • Teach proper nose pinching technique.
  • Avoid trauma or irritants.
  • Manage systemic illnesses and medication compliance.

PROGNOSIS

  • Most epistaxis self-limited.
  • Good outcomes with appropriate treatment.

COMPLICATIONS

  • Septal perforation.
  • Pressure necrosis of nasal mucosa.
  • Toxic shock syndrome (with packing).
  • Arrhythmias (especially with posterior packing).

REFERENCES

  1. Tunkel DE, Anne S, Payne SC, et al. Clinical practice guideline: nosebleed (epistaxis) executive summary. Otolaryngol Head Neck Surg. 2020;162(1):8-25.
  2. Gottlieb M, Long B. Managing Epistaxis. Ann Emerg Med. 2023;81(2):234-240.
  3. Biggs TC, Nightingale K, Patel NN, et al. Prophylactic antibiotics in epistaxis patients with nasal packs? Ann R Coll Surg Engl. 2013;95(1):40-42.

CODES

  • ICD10 R04.0 Epistaxis

CLINICAL PEARLS

  • Most epistaxis is anterior and responds well to pressure over anterior nares for 5-20 minutes.
  • Most nosebleeds are idiopathic or due to digital trauma (nose picking).
  • Posterior bleeds may be asymptomatic or present with nausea, hematemesis, or heme-positive stool.
  • Evaluate for neoplasm if recurrent unilateral epistaxis.