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Emergency And Acute Medicine - Epistaxis
Basic description
Epistaxis is a frequent emergency presentation that is typically mild and self-limited but can occasionally be life threatening. The lifetime incidence is approximately 60%, with most cases occurring in children younger than 10 years. Males are affected more often than females. Severe hemorrhage requiring surgical intervention is more common in patients older than 50 years.
Epistaxis occurs more frequently in low-humidity environments, during winter months, in northern climates, and at high altitude.
The nasal cavity receives blood supply from both the internal and external carotid arteries. Management depends on the location of bleeding.
Anterior epistaxis accounts for about 90% of cases and is usually visualized directly in the anterior nasal cavity. The most common source is Kiesselbach plexus on the anteroinferior nasal septum. Less commonly, bleeding originates from the posterior nasal floor or septum.
Posterior epistaxis represents about 10% of cases and arises from vessels not directly visualized, most often branches of the sphenopalatine artery.
Etiology
Idiopathic causes include dry nasal mucosa related to low humidity.
Foreign bodies are common in children and in patients with psychiatric illness or developmental delay.
Infectious causes include rhinitis, sinusitis, nasal diphtheria, and nasal mucormycosis.
Allergic rhinitis is a frequent contributor.
Trauma includes nose picking, postoperative injury, facial trauma, and barotrauma.
Environmental irritants include ammonia, gasoline, sulfuric acid, and glutaraldehyde.
Intranasal neoplasms include papilloma and other tumors.
Coagulopathies include hemophilia A or B, von Willebrand disease, thrombocytopenia from liver disease, leukemia, chemotherapy, viral illness, or autoimmune disease.
Platelet dysfunction may occur with renal disease or chronic alcohol use.
Medication-related causes include salicylates, NSAIDs, heparin, and warfarin.
Other causes include hereditary hemorrhagic telangiectasia, atherosclerosis of nasal vessels, and endometriosis.
Diagnosis – signs and symptoms
History
Determine laterality, severity, and duration of bleeding.
Assess recurrence and prior episodes.
Ask about nasal obstruction, vomiting or coughing blood, known tumors, or bleeding disorders.
Easy bruising or unusual bleeding suggests an underlying coagulopathy.
Identify comorbid conditions that may be worsened by blood loss, such as coronary artery disease or chronic lung disease.
Physical examination
Assess vital signs for evidence of hemorrhagic shock.
Look for signs of coagulopathy including bruising, petechiae, or purpura.
Inspect the nasal cavity after topical anesthesia and vasoconstriction using a nasal speculum.
Evaluate for blood in the mouth or oropharynx.
Essential workup
Assess airway and hemodynamic stability.
Determine whether bleeding is anterior or posterior.
Evaluate for underlying bleeding disorders when indicated.
Diagnosis tests and interpretation
Laboratory studies
For severe bleeding or suspected coagulopathy consider CBC, type and cross-match, PT/INR, PTT, and BUN.
Diagnostic procedures
Direct visualization with nasal speculum after topical anesthetic and vasoconstrictor. Adequate lighting and suction are essential.
Differential diagnosis
Hematemesis
Hemoptysis
Pediatric considerations
Posterior epistaxis is uncommon in children and should prompt evaluation for bleeding disorders.
Consider foreign bodies or neoplasms such as juvenile angiofibroma.
Use of topical antiseptic ointment for four weeks reduces recurrent epistaxis.
Treatment – prehospital
Stable patients should lean forward, pinch the soft part of the nose, and spit out blood rather than swallow it.
Unstable patients require airway management, IV access, and crystalloid resuscitation.
Initial stabilization and therapy
Secure the airway in patients with altered mental status, facial trauma, or aspiration risk.
Treat hypotension with fluids and blood products as indicated.
Emergency department treatment and procedures
Use universal precautions.
For anterior bleeding, apply direct pressure for 15 minutes.
If bleeding persists, insert cotton pledgets soaked in anesthetic and vasoconstrictor.
Clear clots by gentle blowing, irrigation, or suction.
Cauterize the identified bleeding site with silver nitrate and consider absorbable hemostatic agents.
If cautery fails, anterior nasal packing or balloon devices may be used, ensuring adequate anesthesia and careful placement.
Petroleum-impregnated gauze packing is an alternative when commercial devices are unavailable.
Persistent bleeding after anterior packing suggests inadequate packing or a posterior source.
Posterior epistaxis may require posterior packing with commercial devices or a Foley catheter technique and mandates hospital admission with monitoring.
Posterior packs should not remain in place longer than three days due to infection risk.
Medication
Topical vasoactive agents include cocaine 4%, oxymetazoline with lidocaine, phenylephrine, or anesthetic–epinephrine mixtures.
Antibiotics are required while nasal packing is in place, including amoxicillin–clavulanate, cephalexin, clindamycin, or trimethoprim–sulfamethoxazole.
Follow-up and disposition
Admission criteria
Severe hemorrhage requiring transfusion.
Significant coagulopathy.
Posterior nasal packing, which requires admission, telemetry, oxygen, and specialist consultation.
Anterior packing without reliable follow-up.
Discharge criteria
Hemodynamically stable patients with controlled bleeding.
Use topical oxymetazoline for up to two days, humidification, nasal lubrication, and avoidance of nasal trauma.
All patients discharged with packing must receive antistaphylococcal antibiotics.
Issues for referral
All patients with nasal packing should see an otolaryngologist within 48 hours.
Recurrent unilateral bleeding, nasal obstruction, or suspicious lesions require specialist evaluation.
Follow-up recommendations
Return for uncontrolled bleeding, fever, breathing difficulty, or vomiting.
Avoid nose blowing for 12 hours after bleeding stops.
If bleeding recurs, lean forward and pinch the nose firmly for 10 minutes without interruption.
Use nasal ointment and home humidification as instructed.
Clinical pearls and common missteps
Suspect nasal foreign bodies in unilateral bleeding in children and cognitively impaired patients.
Avoid petroleum-based ointments on anterior nasal balloons due to risk of delayed rupture.
Do not overinflate balloons or pack too tightly, as this may cause tissue necrosis.
Patients with nasal packing should always receive prophylactic antibiotics.
Basic description
Epistaxis is a frequent emergency presentation that is typically mild and self-limited but can occasionally be life threatening. The lifetime incidence is approximately 60%, with most cases occurring in children younger than 10 years. Males are affected more often than females. Severe hemorrhage requiring surgical intervention is more common in patients older than 50 years.
Epistaxis occurs more frequently in low-humidity environments, during winter months, in northern climates, and at high altitude.
The nasal cavity receives blood supply from both the internal and external carotid arteries. Management depends on the location of bleeding.
Anterior epistaxis accounts for about 90% of cases and is usually visualized directly in the anterior nasal cavity. The most common source is Kiesselbach plexus on the anteroinferior nasal septum. Less commonly, bleeding originates from the posterior nasal floor or septum.
Posterior epistaxis represents about 10% of cases and arises from vessels not directly visualized, most often branches of the sphenopalatine artery.
Etiology
Idiopathic causes include dry nasal mucosa related to low humidity.
Foreign bodies are common in children and in patients with psychiatric illness or developmental delay.
Infectious causes include rhinitis, sinusitis, nasal diphtheria, and nasal mucormycosis.
Allergic rhinitis is a frequent contributor.
Trauma includes nose picking, postoperative injury, facial trauma, and barotrauma.
Environmental irritants include ammonia, gasoline, sulfuric acid, and glutaraldehyde.
Intranasal neoplasms include papilloma and other tumors.
Coagulopathies include hemophilia A or B, von Willebrand disease, thrombocytopenia from liver disease, leukemia, chemotherapy, viral illness, or autoimmune disease.
Platelet dysfunction may occur with renal disease or chronic alcohol use.
Medication-related causes include salicylates, NSAIDs, heparin, and warfarin.
Other causes include hereditary hemorrhagic telangiectasia, atherosclerosis of nasal vessels, and endometriosis.
Diagnosis – signs and symptoms
History
Determine laterality, severity, and duration of bleeding.
Assess recurrence and prior episodes.
Ask about nasal obstruction, vomiting or coughing blood, known tumors, or bleeding disorders.
Easy bruising or unusual bleeding suggests an underlying coagulopathy.
Identify comorbid conditions that may be worsened by blood loss, such as coronary artery disease or chronic lung disease.
Physical examination
Assess vital signs for evidence of hemorrhagic shock.
Look for signs of coagulopathy including bruising, petechiae, or purpura.
Inspect the nasal cavity after topical anesthesia and vasoconstriction using a nasal speculum.
Evaluate for blood in the mouth or oropharynx.
Essential workup
Assess airway and hemodynamic stability.
Determine whether bleeding is anterior or posterior.
Evaluate for underlying bleeding disorders when indicated.
Diagnosis tests and interpretation
Laboratory studies
For severe bleeding or suspected coagulopathy consider CBC, type and cross-match, PT/INR, PTT, and BUN.
Diagnostic procedures
Direct visualization with nasal speculum after topical anesthetic and vasoconstrictor. Adequate lighting and suction are essential.
Differential diagnosis
Hematemesis
Hemoptysis
Pediatric considerations
Posterior epistaxis is uncommon in children and should prompt evaluation for bleeding disorders.
Consider foreign bodies or neoplasms such as juvenile angiofibroma.
Use of topical antiseptic ointment for four weeks reduces recurrent epistaxis.
Treatment – prehospital
Stable patients should lean forward, pinch the soft part of the nose, and spit out blood rather than swallow it.
Unstable patients require airway management, IV access, and crystalloid resuscitation.
Initial stabilization and therapy
Secure the airway in patients with altered mental status, facial trauma, or aspiration risk.
Treat hypotension with fluids and blood products as indicated.
Emergency department treatment and procedures
Use universal precautions.
For anterior bleeding, apply direct pressure for 15 minutes.
If bleeding persists, insert cotton pledgets soaked in anesthetic and vasoconstrictor.
Clear clots by gentle blowing, irrigation, or suction.
Cauterize the identified bleeding site with silver nitrate and consider absorbable hemostatic agents.
If cautery fails, anterior nasal packing or balloon devices may be used, ensuring adequate anesthesia and careful placement.
Petroleum-impregnated gauze packing is an alternative when commercial devices are unavailable.
Persistent bleeding after anterior packing suggests inadequate packing or a posterior source.
Posterior epistaxis may require posterior packing with commercial devices or a Foley catheter technique and mandates hospital admission with monitoring.
Posterior packs should not remain in place longer than three days due to infection risk.
Medication
Topical vasoactive agents include cocaine 4%, oxymetazoline with lidocaine, phenylephrine, or anesthetic–epinephrine mixtures.
Antibiotics are required while nasal packing is in place, including amoxicillin–clavulanate, cephalexin, clindamycin, or trimethoprim–sulfamethoxazole.
Follow-up and disposition
Admission criteria
Severe hemorrhage requiring transfusion.
Significant coagulopathy.
Posterior nasal packing, which requires admission, telemetry, oxygen, and specialist consultation.
Anterior packing without reliable follow-up.
Discharge criteria
Hemodynamically stable patients with controlled bleeding.
Use topical oxymetazoline for up to two days, humidification, nasal lubrication, and avoidance of nasal trauma.
All patients discharged with packing must receive antistaphylococcal antibiotics.
Issues for referral
All patients with nasal packing should see an otolaryngologist within 48 hours.
Recurrent unilateral bleeding, nasal obstruction, or suspicious lesions require specialist evaluation.
Follow-up recommendations
Return for uncontrolled bleeding, fever, breathing difficulty, or vomiting.
Avoid nose blowing for 12 hours after bleeding stops.
If bleeding recurs, lean forward and pinch the nose firmly for 10 minutes without interruption.
Use nasal ointment and home humidification as instructed.
Clinical pearls and common missteps
Suspect nasal foreign bodies in unilateral bleeding in children and cognitively impaired patients.
Avoid petroleum-based ointments on anterior nasal balloons due to risk of delayed rupture.
Do not overinflate balloons or pack too tightly, as this may cause tissue necrosis.
Patients with nasal packing should always receive prophylactic antibiotics.
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