Nose

Epistaxis

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Epistaxis, Nosebleed, Nasal bleeding

  • 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
  • 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
  • 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]
  • 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
  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 to apply pressure to septum
  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 (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 ball or on soaked Rhinorocket
      3. Topical Tranexamic Acid (TXA)
      4. Topical Thrombin (if on Warfarin)
  7. Exam basics
    1. Use good lighting
    2. Have irrigant and suction (Frazier tip) available
    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]
  • 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
  5. Recurrent unilateral Epistaxis
    1. Consider otolaryngology evaluation for neoplasm
  • References