DESCRIPTION

• Nosebleeds are a common emergency presentation that is usually minor and self-limited but rarely may be life threatening:
  • Lifetime incidence of ~60%:
    • The incidence decreases with age, with most cases seen in children < 10 yr.
    • Male > female
    • Severe bleeds requiring surgical intervention are more common in patients > 50 yr.
    • Occurs more frequently with low humidity during the winter, in northern climates, and at high altitude
• The nasal cavity is supplied with blood vessels originating from both the internal and external carotid arteries.
• Location of the hemorrhage determines therapy:
  • Anterior epistaxis (90% of cases): Bleeding can be visualized in anterior nose.
    • Most commonly bleeding is located at Kiesselbach plexus, an anastomotic network of vessels on the anteroinferior nasal septum.
    • Rarely, bleeding is found on the posterior floor of the nasal cavity or the nasal septum.
• Posterior epistaxis (10% of cases): Bleeding source not within range of direct visualization.
  • Posterolateral branch of sphenopalatine artery

ETIOLOGY

• Idiopathic:
  • Dry nasal mucosa (low humidity)
• Nasal foreign body:
  • Children, mentally retarded patients, psychiatric patients
• Infection:
  • Rhinitis
  • Sinusitis
  • Nasal diphtheria
  • Nasal mucormycosis
• Allergic rhinitis
• Trauma:
  • Nose picking
  • Postoperative
  • Facial trauma
  • Barotrauma
• Environmental irritants:
  • Ammonia
  • Gasoline
  • Sulfuric acid
  • Glutaraldehyde
• Intranasal neoplasia: Most commonly Papilloma
• Coagulopathy:
  • Hemophilia A or B
  • Von Willebrand disease
  • Thrombocytopenia: Liver disease, leukemia, chemotherapy viral illness, or autoimmune disease.
  • Platelet dysfunction: Renal impairment or chronic alcohol consumption
• Drug induced:
  • Salicylates
  • NSAIDs
  • Heparin
  • Coumadin
• Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease)
• Atherosclerosis of nasal vasculature
• Endometriosis

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

History

• Laterality of the bleeding
• Intensity and amount of bleeding from the nares
• Recurrence of epistaxis and history of prior episodes
• Nasal obstruction and the duration of this symptom
• Complaints of vomiting or coughing blood
• Known tumors or coagulopathy
• Unusual bleeding or easy bruising suggests an underlying coagulopathy.
• Presence of systemic disease exacerbated by blood loss (coronary artery disease, chronic obstructive pulmonary disease)

Physical Exam

• Evaluate vitals for hemorrhagic shock
• Careful exam for signs of coagulopathy:
  • Bruises
  • Petechiae and purpura
• Nasopharyngeal inspection:
  • Anesthetize nasopharynx prior to exam with cotton swab soaked in anesthetic and vasoactive agent.
• Attempt to identify bleeding source with nasal speculum
• Blood in mouth or oropharynx

ESSENTIAL WORKUP

• Assess stability: Airway compromise, hypovolemia.
• Determine source (anterior vs. posterior).
• Consider underlying coagulopathy.

DIAGNOSIS TESTS & INTERPRETATION

Lab

• Consider for severe bleeding or suspected coagulopathy:
  • CBC, type and cross-match, PT/INR, PTT, BUN

Diagnostic Procedures/Surgery

Direct visualization of nasal mucosa with nasal speculum:

• Pretreat with topical vasoconstricting agent and anesthetic.
• Ensure adequate lighting (i.e., headlamp) and suction.

DIFFERENTIAL DIAGNOSIS

• Hematemesis
• Hemoptysis

Pediatric Considerations

• Posterior epistaxis is rare in children; consider further workup for bleeding diatheses.
• Consider nasal foreign bodies or neoplasm, such as juvenile angiofibroma or papilloma.
• 4 wk of topical antiseptic ointment decreases incidence of recurrent epistaxis.

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

• Stable patients: Patient should bend forward at the waist; pinch nares closed, and spit out blood rather than swallow it.
• Unstable patients:
  • Intubation, if airway is compromised
  • IV access
  • Crystalloid resuscitation, if signs of hypovolemia

INITIAL STABILIZATION/THERAPY

• Secure the airway in patients who are unconscious, have major facial trauma, or are otherwise at risk of obstruction or aspiration.
• Treat hypotension with crystalloids and blood products, if necessary, and ensure adequate IV access.

ED TREATMENT/PROCEDURES

• Universal precautions against blood/fluid contamination
• Anterior source:
  • Have patient apply direct pressure by pinching nares closed for 15 min. This may control bleeding and assist with visualization.
  • If bleeding persists, use bayonet forceps to place cotton pledgets soaked in vasoconstricting and anesthetic agents into affected nares.
  • If view is obstructed by blood have patient blow nose, or clear blood from view with irrigation and suction.
  • Visualize source of bleeding and cauterize limited area with silver nitrate.
  • Consider Gelfoam or Surgicel packing over cauterized site.
• Anterior nasal packing:
  • Indicated when cautery has failed to control bleeding
  • Associated with significant discomfort and infectious risk of sinusitis and toxic shock
  • Anterior nasal balloon:
    • Check the integrity of the balloons before insertion.
    • Cover with water-based lubricant or viscous lidocaine
    • Insert the device and inflate it slowly to avoid discomfort.
    • Use saline for the inflation if the balloon is to remain in place > a few hours.
  • Preformed nasal tampons:
    • Adequate anesthesia of the nasal passage should be ensured before placing the tampon.
    • Lubricate the tip of the sponge tampon with antibiotic ointment.
    • Insert it at a 45° angle ~1–2 cm into the nasal cavity.
    • Rotate the long axis of the tampon into a horizontal plane and push it firmly back into the nasal cavity.
    • If the pack does not fully expand from the blood, then use saline to complete the expansion.
    • Secure the drawstring to the cheek.
  • Petroleum-jelly–impregnated gauze:
    • Add an antibiotic ointment to the gauze.
    • Ensure that a free end remains outside the nose.
    • Place the gauze as far back as possible, starting on the floor of the nose.
    • Repeat while securing the placed gauze with the speculum until the nose is fully packed.
  • After anterior packing, persistent new bleeding may be a sign of inadequate packing or posterior source.
  • Always treat patients with nasal packing with antibiotics to prevent sinusitis and prevent or limit Staphylococcus aureus infections that can lead to toxic shock syndrome (TSS).
• Posterior source:
  • Early endoscopic visualization and cautery of bleeding source may prevent need for posterior packing and admission.
  • Posterior packing may be accomplished with commercially available devices such as Nasostat or Epistat.
  • If commercial packs are unavailable, a Foley catheter may be directed into posterior nasopharynx until the tip visible in mouth. The balloon is then inflated and the catheter retracted until the balloon is lodged in the posterior nasopharynx. The catheter is then held in place by umbilical clamp.
  • Posterior pack should not be left in > 3 days due to infectious risk. Patient should be admitted and on telemetry while pack in place due to risk of vagal response.
• Complications of posterior packing:
  • Pressure necrosis of posterior oropharynx (do not overfill balloon)
  • Nasal trauma
  • Vagal response with reflex bradycardia
  • Aspiration
  • Infection/TSS
  • Hypoxia

MEDICATION

• Vasoactive solutions:
  • 4% cocaine
  • 1:1 mixture of 2% tetracaine and epinephrine (1:1,000)
  • 1:1 mixture of oxymetazoline 0.05% (Afrin) and lidocaine solution 4%
  • Phenylephrine (Neo-Synephrine)
• Antibiotics: For use while packing in place.
  • Amoxicillin–clavulanate potassium: 250 mg PO q8h
  • Cephalexin: 250 mg PO q6h
  • Clindamycin: 150 mg PO q6h
  • Trimethoprim–sulfamethoxazole: 160/800 mg PO q12h

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Severe blood loss requiring transfusion
• Severe coagulopathy that places the patient at risk of further blood loss
• Posterior nasal packing: Otolaryngology consult and admission for telemetry, supplemental oxygen, possible sedation, and observation; possible further surgical intervention (e.g., arterial ligation or embolization)
• Patients with anterior packing who do not have reliable follow up within 48 hr.

Discharge Criteria

Stable patients:

• Use Afrin nasal spray for 2 days.
• Lubricate nares with an antibiotic ointment.
• Humidify air.
• Avoid nose picking.
• All patients with nasal packing in place should be prescribed an antistaphylococcal antibiotic (amoxicillin–clavulanate, cephalexin, trimethoprim–sulfamethoxazole) for the duration that the packing remains in place for prevention of both acute sinusitis and TSS.

Issues for Referral

• Refer all patients with packing to a specialist within 48 hr.
• Patients with nonvisualized source, suspicious-appearing lesions, recurrent same-side bleeding, or nasal obstruction should be referred to an ORL specialist for an exam to rule out a neoplastic etiology or a foreign body.

FOLLOW-UP RECOMMENDATIONS

• Return to ED for bleeding not controlled by pressure, fever, difficulty breathing, or vomiting.
• Avoid any nose blowing for 12 hr after the bleeding stops.
• Avoid nose picking or putting anything into the nose.
• If the bleeding starts again, sit up and lean forward, pinch the soft part of the nose tightly for 10 min without letting go.
• Avoid lifting heavy objects or doing too much work right away.
• If there is no packing in the nose, put a small amount of petroleum jelly or antibiotic ointment inside the nostril 2 times a day for 4–5 days.
• Use a humidifier or vaporizer at home.

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• Foreign bodies should be suspected in any unilateral nasal bleeding in small children, psychiatric patients, and patients with mental retardation.
• Avoid covering anterior nasal balloons with antibiotic ointment, as petroleum-based materials may cause a delayed rupture of the balloon.
• Avoid overinflating nasal balloons or placing a pack too tightly, as it can cause necrosis and eschars.
• Patients with packings should receive prophylactic antibiotics

ICD9

784.7 Epistaxis

ICD10

R04.0 Epistaxis

[Outline]

• ICD9
• ICD10

• Barnes ML, Spielmann PM, White PS. Epistaxis: A contemporary evidence based approach. Otolaryngol Clin North Am. 2012;45(5):1005–1017.
• Lewis, TJ. Epistaxis. In: Wolfson AB, Harwood-Nuss A, eds. Harwood-Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
• Manes RP. Evaluating and managing the patient with nosebleeds. Med Clin North Am. 2010;94(5):903–912.
• Melia L, McGarry GW. Epistaxis: Update on management. Curr Opin Otolaryngol Head Neck Surg. 2011;19(1):30–35.

Richard E. Wolfe

Christopher M. McCarthy II