II. Pathophysiology

  1. See Nasal Anatomy
  2. Anterior Epistaxis (90%)
    1. Source: Keisselbach's Plexus
  3. Posterior Epistaxis (10%)
    1. Source: Internal Maxillary artery - sphenopalatine branch
    2. More common in elderly

III. Findings: 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

IV. 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 (uncommon cause of Epistaxis)
      2. NSAIDs, Aspirin or Anticoagulant use
    2. Hypertension
      1. Rarely causes Epistaxis
      2. Fuchs (2003) Blood Press 12:145-8 [PubMed]

V. 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

VI. Management: Home

  1. Sit upright and lean forward (avoids aspiration of blood)
  2. Pinch the nose just below the Nasal Bridge for 10-15 minutes
  3. Spray Oxymetazoline or neosynephrine inside nares (2-3 sprays)
  4. Apply cold compress the area around Nasal Bridge
  5. Avoid unhelpful measures
    1. Avoid home Nasal Packing with tissue, gauze or tampon
    2. Avoid ineffective OTC preparations (e.g. Bleedcease, Styptic Pencil)
  6. Indications for Emergency Department evaluation
    1. Epistaxis lasting >30 minute
    2. Persistent Epistaxis due to facial Trauma
    3. Significant Epistaxis (esp. Anticoagulation or antiplatelet use)

VII. 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 15-20 minutes
    1. Squeeze anterior nose just below bridge to apply pressure to septal vessels
  4. Apply topical Oxymetazoline (Afrin) or spray
    1. Also used as pretreatment for exam (see below)
    2. Stops bleeding in up to 65% of cases
      1. Krempl (1995) Ann Otol Rhinol Laryngol 104: 704-6 [PubMed]
  5. Stabilization
    1. Analgesics for pain
    2. Treat Hypertensive Crisis if present
      1. Otherwise Hypertension Management may be deferred until after Epistaxis management
  6. Nasal mucosa pretreatment
    1. Decongest/Vasoconstrict nasal mucosa (Insert with long forceps and leave in for 20 minutes)
      1. Cocaine soaked 2x2 gauze rolled or cotton ball inserted into nose or
      2. Oxymetazoline (Afrin) on cotton pledget, 2x2 gauze or spray or
      3. Lidocaine 2% and Phenylephrine 4% mix 1:1 on cotton ball inserted into nose or
      4. Lidocaine 2% with Epinephrine atomized with MADD atomizer into nare or
      5. Lidocaine/Epinephrine/Tetracaine (LET solution) on cotton ball inserted into nose
    2. Local Anesthesia
      1. Topical Lidocaine with Epinephrine via MADD Atomizer (see Decongestant mixes as above)
      2. Topical Cetacaine
      3. Nebulized Lidocaine for 60 seconds inhaled via nose and mouth
        1. Lidocaine 2%, 4cc or
        2. Lidocaine 4%, 2cc in 2cc of Normal Saline
    3. Hemostatic Agents
      1. See Refractory measures below
      2. Apply to mucosa via MADD atomizer, cotton pledget or on soaked Rhinorocket
      3. Topical Thrombin (if on Warfarin)
      4. Topical Tranexamic Acid (TXA)
        1. Effective for Epistaxis in patients on antiplatelet agents
          1. Zahed (2018) Acad Emerg Med 25(3): 261-6 [PubMed]
  7. Exam basics
    1. Use good lighting
    2. Have irrigant and suction (Frazier tip) available
      1. Author uses Neotach Little Sucker to wall suction even in adults (intended for nicu, picu patients)
    3. Use Eye Protection and mask
    4. Remove clot (critical - Hemostasis is impossible without this)
  8. 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
      1. Identify the bleeding vessel
      2. Roll the Silver Nitrate end back and forth over the bleeding vessel site
      3. Expect a gray-white area to develop
    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 [PubMed]
  9. Bleeding continues
    1. See Nasal Packing
    2. Consider Topical Thrombin spray (especially for patients on Warfarin)
    3. Consider topical Tranexamic Acid (experimental)
      1. Tranexamic Acid IV form applied topically to nasal septum via inserted cotton pledgets
      2. Zahed (2013) am j emerg med 31(9): 1389-92 [PubMed]

VIII. Management: Persistent bleeding

  1. See Anterior Nasal Hemorrhage Management
  2. See Posterior Nasal Hemorrhage Management
  3. Known Coagulopathy
    1. Topical Thrombin (if on Warfarin)
    2. Topical Tranexamic Acid (TXA)
    3. Desmopressin Spray (DDAVP)
  4. Intractable Bleeding
    1. Arterial ligation
  5. Recurrent unilateral Epistaxis
    1. Consider otolaryngology evaluation for neoplasm

IX. Prevention

  1. Sneeze with an open mouth (less pressure within intranasal vessels)
  2. Avoid nasal picking or Trauma
  3. Keep nasal mucosa and septum moist
    1. Consider applying petroleum jelly or similar ointment
    2. Consider humidifier during drier months (e.g. winter)
  4. Spray Intranasal Steroids (e.g. Flonase) away from the nasal septum
    1. Use the left hand to spray the right nare
    2. Use the right hand to spray the left nare

X. References

  1. (2021) Presc Lett 28(6): 35
  2. Bright in Herbert (2013) EM:Rap 13(4): 12
  3. Wu in Herbert (2012) EM:Rap 12(11): 10
  4. Kucik (2005) Am Fam Physician 71:305-12 [PubMed]
  5. Schlosser (2009) N Engl J Med 360(8):784-9 [PubMed]
  6. Tan (1999) Med Clin North Am 83:43-56 [PubMed]

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