II. Pathophysiology
- See Nasal Anatomy
- Anterior Epistaxis (90%)
- Source: Keisselbach's Plexus
- Posterior Epistaxis (10%)
- Source: Internal Maxillary artery - sphenopalatine branch
- More common in elderly
III. Findings: Signs and symptoms
- Nasal bleeding
- Unilateral or Bilateral nares
- Posterior pharynx
- Retrograde into lacrimal duct (rarely)
-
Hypertension
- Often labile
- Not sustained
IV. Causes
- Local (most common)
- Trauma
- Nose picking
- Dry air
- Irritants (e.g. Tobacco smoke, repeated Cocaine use)
- Topical Medications (e.g. Intranasal Steroids)
- Nasal Foreign Body
- Forceful nose blowing
- Nasal surgery
- Intranasal polyp or neoplasm
- Systemic causes (uncommon)
- Bleeding Disorder
- See Bleeding Diathesis (uncommon cause of Epistaxis)
- NSAIDs, Aspirin or Anticoagulant use
- Hypertension
- Rarely causes Epistaxis
- Fuchs (2003) Blood Press 12:145-8 [PubMed]
- Bleeding Disorder
V. Labs
- Indications (rare)
- Bleeding occurs from multiple sites in nose
- Signs of Coagulopathy
- Tests
VI. Management: Home
- Sit upright and lean forward (avoids aspiration of blood)
- Pinch the nose just below the Nasal Bridge for 10-15 minutes
- Spray Oxymetazoline or neosynephrine inside nares (2-3 sprays)
- Apply cold compress the area around Nasal Bridge
- Avoid unhelpful measures
- Avoid home Nasal Packing with tissue, gauze or tampon
- Avoid ineffective OTC preparations (e.g. Bleedcease, Styptic Pencil)
- Indications for Emergency Department evaluation
- Epistaxis lasting >30 minute
- Persistent Epistaxis due to facial Trauma
- Significant Epistaxis (esp. Anticoagulation or antiplatelet use)
VII. Management: Anterior Hemorrhage
- Bleeding sites
- Kiesselbach's Plexus at septum most common site
- Anterior end of inferior turbinate also common
- Position patient leaning forward
- Keeps blood from collecting posteriorly
- Prevents Nausea and airway obstruction
- Apply manual pressure for 15-20 minutes
- Squeeze anterior nose just below bridge to apply pressure to septal vessels
- Apply topical Oxymetazoline (Afrin) or spray
- Also used as pretreatment for exam (see below)
- Stops bleeding in up to 65% of cases
- Stabilization
- Analgesics for pain
- Treat Hypertensive Crisis if present
- Otherwise Hypertension Management may be deferred until after Epistaxis management
- Nasal mucosa pretreatment
- Decongest/Vasoconstrict nasal mucosa (Insert with long forceps and leave in for 20 minutes)
- Cocaine soaked 2x2 gauze rolled or cotton ball inserted into nose or
- Oxymetazoline (Afrin) on cotton pledget, 2x2 gauze or spray or
- Lidocaine 2% and Phenylephrine 4% mix 1:1 on cotton ball inserted into nose or
- Lidocaine 2% with Epinephrine atomized with MADD atomizer into nare or
- Lidocaine/Epinephrine/Tetracaine (LET solution) on cotton ball inserted into nose
- Local Anesthesia
- Topical Lidocaine with Epinephrine via MADD Atomizer (see Decongestant mixes as above)
- Topical Cetacaine
- Nebulized Lidocaine for 60 seconds inhaled via nose and mouth
- Lidocaine 2%, 4cc or
- Lidocaine 4%, 2cc in 2cc of Normal Saline
- Hemostatic Agents
- See Refractory measures below
- Apply to mucosa via MADD atomizer, cotton pledget or on soaked Rhinorocket
- Topical Thrombin (if on Warfarin)
- Topical Tranexamic Acid (TXA)
- Effective for Epistaxis in patients on antiplatelet agents
- Decongest/Vasoconstrict nasal mucosa (Insert with long forceps and leave in for 20 minutes)
- Exam basics
- Use good lighting
- Have irrigant and suction (Frazier tip) available
- Author uses Neotach Little Sucker to wall suction even in adults (intended for nicu, picu patients)
- Use Eye Protection and mask
- Remove clot (critical - Hemostasis is impossible without this)
- Localize and Cautery with Silver Nitrate
- Contraindications
- Bleeding source unclear
- Anticoagulant use (nasal pack instead, cautery unlikely to be effective)
- Apply to localized bleeding source for 30 seconds
- Identify the bleeding vessel
- Roll the Silver Nitrate end back and forth over the bleeding vessel site
- Expect a gray-white area to develop
- Avoid repeated cautery
- Risk of septal perforation
- Do not use on both sides of septum
- Silver Nitrate is equivalent to electrocautery
- Contraindications
- Bleeding continues
- See Nasal Packing
- Consider Topical Thrombin spray (especially for patients on Warfarin)
- Consider topical Tranexamic Acid (experimental)
- Tranexamic Acid IV form applied topically to nasal septum via inserted cotton pledgets
- Zahed (2013) am j emerg med 31(9): 1389-92 [PubMed]
VIII. Management: Persistent bleeding
- See Anterior Nasal Hemorrhage Management
- See Posterior Nasal Hemorrhage Management
- Known Coagulopathy
- Topical Thrombin (if on Warfarin)
- Topical Tranexamic Acid (TXA)
- Desmopressin Spray (DDAVP)
- Intractable Bleeding
- Arterial ligation
- Recurrent unilateral Epistaxis
- Consider otolaryngology evaluation for neoplasm
IX. Prevention
- Sneeze with an open mouth (less pressure within intranasal vessels)
- Avoid nasal picking or Trauma
- Keep nasal mucosa and septum moist
- Consider applying petroleum jelly or similar ointment
- Consider humidifier during drier months (e.g. winter)
- Spray Intranasal Steroids (e.g. Flonase) away from the nasal septum
- Use the left hand to spray the right nare
- Use the right hand to spray the left nare
X. References
- (2021) Presc Lett 28(6): 35
- Bright in Herbert (2013) EM:Rap 13(4): 12
- Wu in Herbert (2012) EM:Rap 12(11): 10
- Kucik (2005) Am Fam Physician 71:305-12 [PubMed]
- Schlosser (2009) N Engl J Med 360(8):784-9 [PubMed]
- Tan (1999) Med Clin North Am 83:43-56 [PubMed]