Epistaxis

A medical term for a nosebleed, which is a common presenting

complaint in the emergency room
 Etiology
Local causes Systemic causes
• Nasal trauma • Bleeding disorders
-Anticoagulant and/or aspirin therapy
-Nose picking (common cause)
-Von Willebrand disease
-Fractures to the middle third of the face, base of -Severe thrombocytopenia (e.g., ITP,
the skull, or the nasal septum leukemia, dengue)
• Foreign body in the nose -Hemophilia
• Dry nose (rhinitis sicca) • Hypertension

• Nasal septal defects (e.g., deviated nasal septum ,

septal perforation)
• Infections (e.g., granulomatous diseases such as
rhinosporidiosis)
• Tumors of the nasopharynx and/or paranasal
sinuses (e.g., juvenile angiofibroma)
• Vascular malformations (e.g., nasal hemangioma,
hereditary hemorrhagic telangiectasia)
• Medications, drugs (e.g., topical corticosteroids,
cocaine)
Classification
Diagnosis
1. Anamnesis
The history should include
-duration, severity, frequency, laterality of the bleeds
-causes
-interventions provided prior to seeking care
-anticoagulant, aspirin, or NSAID use
-drug or alcohol use.
Include family history of coagulopathies and relevant history
2. Physical examination
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
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.
Treatment
1. Immediate measures
• Fluid resuscitation if the patient is hemodynamically unstable
• Keep the patient calm.
• Elevate the upper body and bend the patient's head forward.
• Apply cold packs and sustained, direct pressure by pinching the nose
at the nostrils for 5–10 minutes in order to occlude the bleeding
vessel.
• Apply topical vasoconstrictors (e.g., oxymetazoline, phenylephrine)
2. If epistaxis continues after 10–15 minutes
• First-line: cauterization of the bleeding vessel using silver nitrate or
electrocautery.
• Second-line: nasal packing using gauze impregnated with paraffin and
antibiotics (covering for Staphylococcus aureus).
• Anterior epistaxis: anterior nasal packing
• Posterior epistaxis: posterior nasal packing

3. If epistaxis persists: arterial embolization or endoscopic ligation of

the bleeding vessel
• Anterior ethmoidal artery for anterior epistaxis
• Sphenopalatine artery for posterior epistaxis
Anterior nasal packaging

Posterior nasal packaging

Prognosis
For most of the general population, epistaxis is merely a nuisance.
However, the problem can occasionally be life-threatening, especially in
elderly patients and in those patients with underlying medical
problems.
Fortunately, mortality is rare and is usually due to complications from
hypovolemia, with severe hemorrhage or underlying disease states.