CASE

PRESENTATION
Basant Elbeheiry R1
PATIENT
PRESENTATIO
N

A 9 years old female presented to the

hili clinic complaining of nose
bleeding.

PRESENTATION TITLE 2
HISTORY OF PRESENTING
ILLNESS
The epistaxis has been going on for the past 3 days.
Large amount of fresh blood (bright red)
No blood clots
Lasts for around 10 minutes.
She has experienced recurrent episodes over the past two years.
Right nostril only
History of recent trauma.

PRESENTATION TITLE 3
REVIEW OF SYSTEM:

4
PAST HISTORY

Past medical: none

Past surgical: none
Allergies: none
Family history: older brother has a similar presentation.
Grandfather had a bleeding disorder
•Social history: Non-smoker household. No exposure to
environmental irritants.

PRESENTATION TITLE 5
VITALS

Temp: 36.1
Pulse: 114 bpm
Respiratory rate: 18
Blood pressure: 119/63 mmHg
Oxygen saturation: 99%

PRESENTATION TITLE 6
PHYSICAL EXAMINATION
Weight: 27.5 Kg
Height: 130 cm
BMI: 16.27 Kg/m2

•ENT:
Nasal examination reveals no obvious deformities or lesions.
Dryness and pale right nasal opening.
No signs of active bleeding.
Otherwise, unremarkable examination.

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DIFFERENTIAL DIAGNOSIS
OF EPISTAXIS
1.Nasal Trauma
2.Dry or Irritated Nasal Mucosa
3.Upper Respiratory Infections
4.Allergic Rhinitis
5.Foreign Bodies
6.Coagulation Disorders
7.Hereditary Hemorrhagic Telangiectasia (HHT)
8.Nasal Infections
9.Nasal Structural Abnormalities
10.Vascular Anomalies
11.Medication-Induced
12.Neoplastic Conditions
13.Systemic Conditions
14.Environmental Factors
8
15.Rare Genetic Syndromes
LABS

CBC with differentials

AST.ALT
Coagulation profile
Electrolytes
All labs are normal

PRESENTATION TITLE 9
EPISTAXIS
Classification of epistaxis
Criteria
Clinical features
Relative frequency
Peak incidence [5]
Most common site of bleeding
Anterior epistaxis
•Bleeding from the nostrils
•∼ 90% of cases
•Children < 10 years of age
•Kiesselbach plexus: an anastomosis of four
arteries (anterior ethmoidal artery,
sphenopalatine artery, greater palatine artery,
and superior labial artery) located in the
anteroinferior portion of the nasal septum
(Little area)
PRESENTATION TITLE
Posterior epistaxis
•Bleeding through the posterior nasal aperture
• Bleeding down the throat (no external
signs of bleeding)
• Hemoptysis, hematemesis, and/or
melena may occur due to swallowing
of large amounts of blood.
•∼ 10% of cases
•Older individuals (> 50 years of age)
•Woodruff plexus: a collection of arteries
located in the posteroinferior region of the
lateral nasal cavity, formed by anastomoses of
the sphenopalatine artery (branch of the
maxillary artery) and pharyngeal artery [6]
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CLINICAL FEATURES

PRESENTATION TITLE 12
DIAGNOSIS
Clinical diagnosis

1.Complete Blood Count (CBC)

2.Coagulation Profile (PT, aPTT)
3.Nasal Endoscopy: To assess for any structural abnormalities or lesions within
the nasal cavity.
4.Assessment for Allergies: Skin prick testing or blood tests if indicated.

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 LABS

Coagulation Liver function

CBC Bleeding time GH and TSH
profile tests

Thrombocytopenia or Prothrombin Time bleeding time may be Assessing liver

qualitative platelet (PT) and Activated ordered to assess function may be
defects may Partial platelet function relevant if liver
contribute to bleeding Thromboplastin Time disease is suspected
disorders. (aPTT) can identify
CBC helps assess for clotting abnormalities
anemia or other blood and screen for
disorders, including bleeding disorders
platelet abnormalities.

PRESENTATION TITLE 14
 LABS

Nasal endoscopy Nasal imaging Angiography vWF Allergic testing

identify structural Computed In cases of suspected A specific test to Skin prick tests or
abnormalities, such as Tomography (CT) or vascular assess for von blood tests (specific
septal deviation, nasal Magnetic Resonance abnormalities, Willebrand disease, a IgE levels) can help
polyps, or tumors. Imaging (MRI) of the imaging of the blood hereditary bleeding identify allergic
nasal and sinus vessels may be disorder rhinitis as a potential
structures may be performed. cause of epistaxis.
performed to evaluate
for anatomical
abnormalities or
tumors.

PRESENTATION TITLE 15
 MANAGEMENT

•Stabilize patients
•Keep the patient's head elevated and tilted forward.
•Control bleeding by applying uninterrupted, bilateral pressure.
• Clear the nose of blood clots.
• Pinch the nasal ala against the nasal septum for 15–20 minutes.
• Consider concurrent use of a topical vasoconstrictor.
•Perform anterior rhinoscopy to identify the source of bleeding.

PRESENTATION TITLE 16
 MANAGEMENT

•If bleeding persists or the bleeding site cannot be identified, place nasal packing.
• Perform anterior nasal packing
• If unsuccessful, consult ENT and perform posterior packing, e.g., with a nasal balloon or Foley
catheter.
•For refractory or recurrent bleeding, consider arterial embolization or endoscopic ligation of the bleeding
vessel, i.e.:
• Anterior ethmoidal artery for anterior epistaxis
• Sphenopalatine artery for posterior epistaxis

PRESENTATION TITLE 17
 SAFETY NETTING

•Patient can’t stop the bleeding after more than 15 to 20 minutes of applying direct pressure on your nose as
described in the steps above.
•The bleeding is rapid, or the blood loss is large (more than 1 cup).
•Having difficulty breathing.
•Vomited due to swallowing a large amount of blood.
•nosebleed has followed a blow to your head or a serious injury (fall, car accident or a smash to face or nose).

PRESENTATION TITLE 18
THANK YOU

PRESENTATION TITLE 19