Epistaxis, or nasal bleeding, is a common, usually benign, self-limited condition which may be recurrent. Many cases do not require medical attention, although in some rare circumstances it can lead to massive hemorrhage and death. Epistaxis has been reported to occur in up to 60 percent of the general population, with peak incidence in those aged 2 to 10 and 50 to 80 (Am Fam Phys 2005;71:305), and is more common in male patients.
Local and systemic factors can lead to bleeding. Most nosebleeds are reported as spontaneous events with no easily identifiable cause. Many are related to nose picking (epistaxis digitorum) or other trauma (nasal/facial fracture, nasogastric, nasotracheal, or foreign body insertion). Bleeding typically occurs when the mucosa is eroded and vessels become exposed and rupture. Bleeding also may be exacerbated by use of medications/ingestion (e.g., anticoagulants, topical corticosteroids, aspirin, nonsteroidal anti-inflammatory drugs, coumarin plant poisoning, rodenticide), intranasal cocaine, migraines (unknown etiology), hypertension, irritants (e.g., cigarette smoke), chronic sinusitis, bleeding disorders (e.g., von Willebrand disease, hemophilia, thrombocytopenia, platelet dysfunction, disseminated intravascular coagulation), liver disease, sclerotic vessels, gastroesophageal reflux in young infants, hereditary hemorrhagic telangiectasia, Osler-Weber-Rendu syndrome, endometriosis, barotrauma, vascular malformation, malignancy (e.g., intranasal neoplasm, leukemia), or exposure to warm and dry air causing dry membranes (rhinitis sicca).
Epistaxis is typically defined by the origin of the bleeding, anterior or posterior. This simplifies the complex vascular network originating from the ethmoid branches of the internal carotid arteries and the sphenopalatine and internal maxillary divisions of the external carotid arteries. More than 90 percent of bleeds occur anteriorly and arise from the arterial anastomoses on the nasal septum (Kiesselbach's plexus/Little's area). Bleeding of these capillaries tends to produce a constant ooze, rather than the classic arterial pumping of blood. Posterior bleeds are usually more profuse and difficult to control. Because of their location, posterior bleeds represent a greater risk for airway compromise and the aspiration of blood.
Anterior bleeding tends to be clinically obvious, but posterior bleeding can be more insidious. Massive posterior bleeding can be confused with hemoptysis or hematemesis and may result in melena and anemia. However, blood dripping from the posterior nasopharynx classically confirms a nasal source.
Identifying the source of bleeding is the key to managing epistaxis. Have the patient blow his nose to remove clots so that direct visualization of the bleeding source is easier to locate. A large otologic nasal speculum, a nasal suction apparatus, a well-lighted room, and head-mounted light source are helpful to directly visualize and evacuate clots. Many EDs have developed an epistaxis tray which includes many of the tools and equipment necessary to treat epistaxis. The patient and physician should be gowned to prevent blood contamination, and universal precautions should be followed.
Initial management should include application of direct pressure to the area of bleeding (usually the septum). Have the patient hold firm external compression on the nares for five to 20 minutes. Tilting the head forward prevents blood from pooling in the posterior pharynx and can help prevent nausea and airway compromise. Some have described the use of clamp-like grips other than the patients' hand to hold external pressure (e.g,. two tongue depressors taped together at one end and placed on patients nose like a clothespin), but this does not work well in my experience. Insertion of a cotton ball, gauze, or cotton pledgets soaked with topical vasoconstricting solution (e.g., 4% cocaine solution, oxymetazoline/Afrin, or phenylephrine/Neo-Synephrine) can help tamponade the bleeding vessels, and result in hemostasis especially in cases of diffuse oozing or multiple bleeding sites. Keep in place for 10 to 15 minutes. Addition of topical local anesthetic, such as tetracaine or lidocaine/ Xylocaine solution will reduce associated discomfort.
After direct pressure is held, identify any isolated sites of bleeding that may be amenable to cautery with a silver nitrate stick. Apply directly to the bleeding site until grey eschar is formed; perform unilaterally only to prevent septal perforation. (Med Clin North Am 1999;83:43.) Inspect the posterior pharynx looking for a constant dripping of blood, which suggests a posterior rather than an anterior bleeding source.
Patients who are hemodynamically unstable will require crystalloid and standard monitoring and resuscitation. Prompt identification of airway compromise is important. Diffuse oozing, multiple bleeding sites, or recurrent bleeding may indicate a systemic process (e.g., hypertension, anticoagulation, or coagulopathy), which requires a hematologic evaluation including a complete blood count, coagulation studies, and possible administration of blood products. (Aust Fam Physician 2000;29:933; J Oral Maxillofac Surg 2000;58:419.) High blood pressure itself is rarely the primary cause of epistaxis, but it may impede clotting.
Refractory bleeding may be amenable to insertion of hemostatic packing agents such as gelatin foam (Gelfoam), oxidized cellulose (Surgicel), or antifibrolynitic compounds (Floseal, Cyklokapron). (Curr Opin Otolaryngol & Head & Neck Surg 2007;15(3):180.) Desmopressin spray (DDAVP) may be considered in a patient with a known bleeding disorder. (Am Fam Phys 2005;71:305.) If anterior bleeding continues, placement of anterior packing is indicated. There are many possible anterior packing techniques and agents, including placement of ribbon gauze impregnated with lubricant via Bayonet forceps or a nasal tampon (Merocel or Doyle sponge, Rhino Rocket, Medwick foam pack, Slik-Pak, Rapid Rhino, EPI-STOP balloon, etc.) covered with lubricant plus a small amount of vasoconstricting agent.
Because prolonged nasal packing increases the risk of developing toxic shock syndrome, the use of a topical antistaphylococcal antibiotic ointment on the packing materials has been recommended. (Am Fam Phys 2005;71:305.) No significant difference in efficacy or patient comfort between nasal tampons or ribbon gauze packing has been reported. (Clin Otolaryngol 1995;20:305.) Anterior nasal packing may be left in place for three to five days to ensure formation of an adequate clot. (J Oral Maxillofac Surg 2000;58:419.)
Complications of nasal packing include septal hematoma, nasal abscess, sinusitis, neurogenic syncope during packing, and pressure necrosis secondary to excessively tight packing.
After placement of an anterior pack, reassess the pharynx. If bleeding continues with an anterior pack in place, strongly consider a posterior bleed. Posterior bleeding can be treated with packing (which is technically difficult) or use of various balloon systems. A (10 to 16 French) Foley catheter with a 30 mL balloon inflated with approximately 15 ml of sterile water also may be used as a temporizing agent. Care should be taken to secure any packing device to the external face to prevent slippage and subsequent aspiration of the packing. Posterior packing can potentially cause airway compromise and respiratory depression. For this reason, it is recommended that patients are admitted to a monitored setting with otolaryngology consultation. Endoscopic ligation of the sphenopalatine artery is now emerging as the most effective and cost-efficient treatment for posterior epistaxis. (Curr Opin Otolaryngol & Head & Neck Surg 2007;15:180.)
The patient presented here admitted to cocaine use just prior to the start of his epistaxis. After placement of an anterior nasal pack, the bleeding resolved. He was discharged from the ED, given a prescription for oral antibiotics and analgesia, and told to follow up with ENT in 48 to 72 hours.