Epistaxis (Nose Bleed)


Article Author:
Ayesha Tabassom


Article Editor:
Julia Cho


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
1/30/2019 10:28:53 AM

Introduction

Epistaxis (nosebleeds) is one of the most common ear, nose, and throat (ENT) emergencies that present to the emergency room or primary care. There are two types of nosebleeds: anterior (more common), and posterior (less common, but more likely to require medical attention). The source of 90% of anterior nosebleeds within the Kiesselbach plexus (also known as Little’s area) on the anterior nasal septum. The sphenopalatine artery (SPA) is the most probable source for posterior bleeds. [1][2][3]

Nosebleeds can be divided into primary or secondary. Primary nosebleeds are idiopathic and spontaneous.  Secondary bleeds have clear and definite causes like trauma or anticoagulation use.

Etiology

There are multiple causes of epistaxis which can be divided into local, systemic, environmental, and medication induced. Local causes can include digital manipulation, a deviated septum, trauma, inhaled corticosteroids, and chronic nasal cannula use. Systemic causes can include alcoholism, hypertension, vascular malformations, or coagulopathies (von Willebrand disease, hemophilia). Environmental factors can include allergies or dryness during winter months. Medications include NSAIDS (ibuprofen), anticoagulants (warfarin), platelet aggregation inhibitors (clopidogrel), or supplement/alternative medications. It is important to consider other etiologies/malignancies if the patient has red flags such as unilateral nasal blockage, facial pain, headaches, or facial deformity. Drug use (cocaine) use should be considered in adolescent patients.[4][5][6]

Epidemiology

Nosebleeds are rarely fatal, accounting for only four of the 2.4 million deaths in the United States. About 60% of people have experienced a nosebleed during their life, and only 10% of nosebleeds are serious and warrant treatment/medical intervention. They occur most commonly in children ranging from 2 to 10 years old and the elderly ranging from 50 to 80 years old.  

Pathophysiology

Nosebleeds are caused by the rupture of a blood vessel within the nasal mucosa. Rupture can be spontaneous, initiated by trauma, use of certain medication, and/or secondary to other comorbidities or malignancies. An increase in the patient's blood pressure can increase the length of the episode. Anticoagulant medications, as well as clotting disorders, can also increase the bleeding time.

Most nosebleeds occur in the anterior part of the nose which has a lot of blood vessels (Kiesselbach's plexus). This region is also known as Little's area.

Bleeding from the back of the nose is known as a posterior bleed.  This is usually due to bleeding from Woodruff's plexus. These are often difficult to control and are associated with bleeding from both nostrils.  It can generate a greater flow of blood into the posterior pharynx and have a higher risk for airway compromise or aspiration due to increased difficulty in controlled the bleed.

History and Physical

The history should include duration, severity, frequency, laterality of the bleeds, cause, and interventions provided prior to seeking care.  In regards to medication use, be sure to ask about anticoagulant, aspirin, or NSAID use.  Include family history of coagulopathies and relevant history.  Ask of any drug or alcohol use.

Before completing a physical exam, prepare proper equipment and proper personal protective equipment (PPE).  Equipment may include a nasal speculum, bayonet forceps, headlamp, suction catheter, packing, silver nitrate swabs, cotton pledgets, and anesthetic available. Have the patient seated in a sniffing position by having patient flex and extend head while keeping the base of nose straight ahead. Carefully insert the speculum and slowly open the blades to visualize the bleeding site.

Evaluation

Differentiating an anterior or posterior is key in management. Diagnosis of anterior bleeding is can be made by direct visualization using a nasal speculum and light source. A topical spray with anesthetic and epinephrine may be helpful for vasoconstriction to help control bleeding and to aid in visualization of the source. Usually, diagnosis of posterior bleeding is made after measures to control anterior bleeding have failed. Clinical features of posterior bleeding can include bleeding in the elderly with either inherited or acquired coagulopathy, hemorrhage from bilateral nares, or significant blood noted in the posterior nasopharynx. Labs may be obtained if necessary, including a complete blood cell count (CBC), type and cross match, and coagulation studies. Occasionally, imaging such as x-ray or a CT may also be needed.

Treatment / Management

Start with a primary survey and address airway, ensure the airway is patent.  Next, assess for hemodynamic compromise. Obtain large bore intravenous access in patients with severe bleeding and obtain labs. Reverse blood clotting as necessary, if concern with medication use.[7][8][9]

Treatment for anterior bleeding can be started with direct pressure. Have the patient apply constant direct pressure by pinching the nose over the cartilaginous tip (instead of over the bony areas) for a few minutes to try to control the bleed. If that is ineffective, chemical cauterization with silver nitrate, thrombogenic foams or gels, anterior nasal packing, anterior epistaxis balloons, or nasal tampons (Rapid Rhino) may be considered.

If none of this works, the bleeding may be from the posterior nasal cavity. Symptoms can include bleeding from both nostrils or blood present in the posterior pharynx. Posterior nasal packing may be used as a temporary measure while waiting for ENT consult.  It is associated with higher rates of complications like pressure necrosis, infection or hypoxia. Foley catheters can be used by experienced personnel to tamponade a posterior bleed. Other options for uncontrolled bleeding include external artery, internal maxillary artery or sphenopalatine artery ligation, with sphenopalatine artery ligation being widely used. Angiographic embolization of the bleeding vessel is an alternative for sphenopalatine artery ligation for patients who are unfit for general anesthesia or who have failed a prior sphenopalatine artery ligation.

Pearls and Other Issues

Patients with anterior nosebleeds can be discharged if the bleeding is controlled and hemodynamic stability is observed for at least one hour in the Emergency Department (ED). Follow up with ENT should occur within 48 hours. If non-biodegradable packing is used, patients should return to the ED or ENT for packing removal in two to three days. If a patient, including pediatric patients, require posterior packing, admission may be warranted to monitor for complications.  Patients on warfarin can continue using it if INR levels are within desired range, NSAIDs should be discontinued for three to four days.

Application of a topical ointment to the nasal mucosa to ensure moisturisation of the nasal mucosa for a few days can help to prevent recurrent epistaxis. Patients should also be advised to avoid hot foods, strenuous activity, blowing nose, or digital manipulation of the nose on discharge.

Enhancing Healthcare Team Outcomes

The majority of patients with a nose bleed present to the emergency department. While most anterior nosebleeds can be arrested with digital pressure, a follow-up appointment is recommended in patients with repeat episodes. Nasal packing is another option but the packing must be removed in 24-48 hours. Drug-induced nosebleeds may require reversal of the INR and admission. In rare cases, embolization or cauterization may be required to stop a nose bleed. The outcomes for more patients with nose bleeds is good.

 


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Epistaxis (Nose Bleed) - Questions

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Epistaxis can be a life-threatening emergency. Which of the following is false?



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What is the most common site of epistaxis?



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What used to be the anesthetic of choice for epistaxis?



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Which of the following statements about epistaxis is true?



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A 16-year-old presents with a nosebleed. Examination reveals a small bleeding area along the anterior septum. What is the ideal treatment?



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What is the best initial treatment for a child with acute epistaxis who is not responding to manual pressure?



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What is the best next step in the management of a child with a nosebleed who has failed manual pressure?



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Which of the following is false about a patient who has epistaxis for 3 hours?



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Which is not true regarding posterior epistaxis?



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Which is false about epistaxis?



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Which of the following instruction is important for children and parents in the event of nose bleed?



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What is the most common cause of nosebleeds in young children?



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A 70-year-old man presents with sudden onset of epistaxis from both nares. Visualization shows blood in the posterior nasopharynx. Direct pressure has not helped stop the bleeding. Neither silver nitrate nor packing or a nasal tampon has helped. Which artery could be a possible source of the bleeding?



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Which of the following is not used as surgical options for treatment of epistaxis after other treatments have failed?



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A young male presents to the emergency department with a moderate nose-bleed that failed to stop with digital pressure. After a nose pack is applied, the bleeding stops. What instructions will the nurse reinforce with the patient upon discharge? Select all that apply.



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A 16-year-old male presents to the emergency department for evaluation of acute onset spontaneous right-sided epistaxis. Upon examination, there is a continuous trickle of blood from the right naris. Inspection of the posterior oropharynx reveals no blood or clots. Which of the following is the most likely source of bleeding in this patient?



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A 16-year-old male presents to the emergency department with a nosebleed that has been ongoing for about 2 hours. The patient was in a summer camp participating in a 10 km race in the hot, dry weather. On examination, there is bleeding from his right nares and no oropharyngeal lesions. There is no history of nasal or facial trauma. Blood pressure is 103/71 mm Hg, and pulse is 93 beats/min. The clinician pinches the anterior nasal septum and applies pressure for 10 minutes while the patient is leaning forward, but the bleeding does not stop. The clinician then sprays oxymetazoline on a cotton pledget and inserts it into the anterior nose and applies pressure for another 10 minutes, but the bleeding does not stop. What is the next best step in the management of this patient?



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Epistaxis (Nose Bleed) - References

References

Fishman J,Fisher E,Hussain M, Epistaxis audit revisited. The Journal of laryngology and otology. 2018 Dec;     [PubMed]
Send T,Bertlich M,Eichhorn KW,Ganschow R,Schafigh D,Horlbeck F,Bootz F,Jakob M, Etiology, Management, and Outcome of Pediatric Epistaxis. Pediatric emergency care. 2019 Jan 7;     [PubMed]
Kitamura T,Takenaka Y,Takeda K,Oya R,Ashida N,Shimizu K,Takemura K,Yamamoto Y,Uno A, Sphenopalatine artery surgery for refractory idiopathic epistaxis: Systematic review and meta-analysis. The Laryngoscope. 2019 Jan 6;     [PubMed]
Mehta N,Stevens K,Smith ME,Williams RJ,Ellis M,Hardman JC,Hopkins C, National prospective observational study of inpatient management of adults with epistaxis - a National Trainee Research Collaborative delivered investigation. Rhinology. 2019 Jan 5;     [PubMed]
Clark M,Berry P,Martin S,Harris N,Sprecher D,Olitsky S,Hoag JB, Nosebleeds in hereditary hemorrhagic telangiectasia: Development of a patient-completed daily eDiary. Laryngoscope investigative otolaryngology. 2018 Dec;     [PubMed]
Ramasamy V,Nadarajah S, The hazards of impacted alkaline battery in the nose. Journal of family medicine and primary care. 2018 Sep-Oct;     [PubMed]
Joseph J,Martinez-Devesa P,Bellorini J,Burton MJ, Tranexamic acid for patients with nasal haemorrhage (epistaxis). The Cochrane database of systematic reviews. 2018 Dec 31;     [PubMed]
Wong AS,Anat DS, Epistaxis: A guide to assessment and management. The Journal of family practice. 2018 Dec;     [PubMed]
Santander MJ,Rosenbaum A,Winter M, Topical tranexamic acid for spontaneous epistaxis. Medwave. 2018 Dec 10;     [PubMed]

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