Ovid: 5-Minute Sports Medicine Consult, The

David Z. Frankel
  • Bleeding from injured nasal mucosa overlying a blood vessel
  • Self-induced digital trauma (nose picking) is the most common etiology, particularly among children.
  • Affected persons usually do not seek medical attention, especially if bleeding is minor or self-limited.
  • Synonym(s): Nosebleed; Nasal bleeding
  • Common problem that is estimated to occur in 60% of the general population
  • 90% of cases occur along the anterior nasal septum at Kiesselbach's plexus.
  • Bimodal age distribution with incidence peaks at ages <10 yrs and >50 yrs
  • Local causes:
    • Local digital trauma
    • Low moisture content in ambient air
    • Nasal septal deviation
    • Intranasal neoplasm or polyps
    • Chemical irritants (eg, cigarette smoke)
    • Medications (eg, intranasal steroids)
    • Allergic or viral rhinitis
    • Chronic sinusitis
    • Facial trauma
    • Foreign body
    • Septal perforation
    • Illicit drug use (eg, cocaine)
    • Aneurysm
    • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)
    • Iatrogenic instrumentation
  • Systemic causes:
    • Coagulopathies (eg, Von Willebrand disease, hemophilia)
    • Renal failure
    • Platelet dysfunction
    • Thrombocytopenia
    • Hematologic malignancies (eg, leukemia)
    • Alcoholism
    • Hypertension
    • Liver disease (eg, cirrhosis)
    • Medications (eg, aspirin, NSAIDs, anticoagulants)
  • Laterality of nosebleed
  • Amount of blood loss
  • Severity
  • Duration
  • Frequency
  • Presence of nasal obstruction: May indicate a neoplasm, especially with recurrent bleeding from the same side
  • Trauma: Consider other associated injuries.
  • Other medical conditions that predispose to bleeding:
    • Tumors and coagulation disorders
    • Cirrhosis
    • HIV infection
    • Intranasal cocaine use
  • The presence of chronic medical conditions that can be exacerbated by blood loss:
    • Coronary artery disease
    • Chronic obstructive pulmonary disease
  • Medications:
    • Aspirin
    • NSAIDs
    • Anticoagulants
    • Intranasal steroids
  • Alcohol use
  • History of severe nosebleeds or easy bruising
  • Family history of bleeding disorders
Physical Exam
  • Initial evaluation should focus on airway assessment and cardiovascular stability, looking for signs of airway compromise or hypovolemia.
  • Pretreatment/initial tamponade:
    • The patient should blow his or her nose to remove blood and clots.
    • Local anesthetic and vasoconstrictor should be applied as a topical spray or via saturated cotton pledgets.
      • Drugs commonly used for this purpose are lidocaine and oxymetazoline (Afrin).
      • One small retrospective study found that oxymetazoline spray stopped the bleeding in 65% of consecutive patients with epistaxis presenting to the ED.
    • The patient should be sitting up and leaning forward to prevent blood from tracking into the pharynx.
    • The patient should apply direct pressure over the upper lip for 5 min and by tightly pinching the nasal alae (soft cartilaginous part of the nose) against the septum continuously for 10–15 min.
    • A cold compress applied over the bridge of the nose may help with hemostasis.
  • Physical examination:
    • The examination should take place in a well-lighted room, preferably with a headlamp or mirror.
    • The patient should be seated comfortably in an upright position with head movement restricted.
    • An adequate examination for the source of bleeding requires use of a nasal speculum.
    • Clots and foreign bodies in the anterior nasal cavity can be removed with suction (Frazier suction catheter), irrigation, forceps, and cotton-tipped applicators.
    • If no anterior source is identified, a nasal endoscope can be used to visualize the remainder of the nasal cavity.
    • Posterior bleeding may be subtle, and the general location of the source of bleeding should be determined (eg, behind the middle turbinate, roof of the nasal cavity, submucosal masses).
    • This is important because different arteries supply the floor and roof of the posterior nasal cavity.
    • Epistaxis from nasal trauma warrants an evaluation for fracture.
    • Deformity of the bony structures may be notable, and palpation of the bony structures may reveal tenderness.
    • Evaluate extraocular muscle movements and stability of the teeth to rule out orbital or maxillary fracture.
    • CSF leak should be ruled out using the ring test, if indicated.
    • In patients with recurrent nosebleeds, evaluate for signs of coagulopathy (eg, ecchymoses, petechiae, telangiectatic lesions).
Diagnostic Tests & Interpretation
  • Laboratory studies should be dictated by the history, physical examination, and severity of bleeding.
  • For severe bleeding, a CBC should be performed in addition to blood type and crossmatching for possible transfusion.
  • In anticoagulated patients, coagulation studies may be required to determine if anticoagulation levels are supratherapeutic.
  • In patients with systemic conditions that could lead to coagulopathy, testing for hepatic or renal dysfunction may be required.
  • Even when testing is done selectively, the results are normal in nearly 80% of patients.
  • Radiographic studies are usually not helpful unless nasal or facial fracture is suspected.
  • Unexplained recurrent unilateral epistaxis should raise suspicion for neoplasm and warrants consideration of CT scan or MRI and endoscopic evaluation.
Differential Diagnosis
  • Pulmonary hemoptysis
  • Upper GI bleed such as bleeding esophageal varices
  • Tumor bleeding from the pharynx, larynx, or trachea


Ongoing Care
  • Once epistaxis is controlled, conservative measures may prevent recurrent bleeding owing to local factors.
  • Refrain from activities that may stimulate bleeding:
    • Blowing or picking nose
    • Heavy lifting
    • Strenuous activity
  • Patient should abstain from alcohol or hot drinks that may cause vasodilatation of the nasal vessels.
  • Nasal saline washes and water-soluble ointments assist in humidification of the nasal mucosa and promote healing.
  • Humidified air, especially for patients using oxygen via nasal canula, may improve local conditions within the nose.
Follow-Up Recommendations
  • Patients should meet with their primary care physician to search for and address underlying causes and risk factors for epistaxis.
  • All patients with recurrent epistaxis, particularly if unilateral, require formal evaluation with radiographic studies and nasal endoscopy to rule out a neoplastic lesion.
Additional Reading
Alter H. Approach to the adult with epistaxis. In: UpToDate, Basow DS (Ed), UpToDate, Waltham, MA, 2009.
Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. 2008;41:525–536, viii.
Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005;71:305–311.
Leong SC, Roe RJ, Karkanevatos A. No frills management of epistaxis. Emerg Med J. 2005;22:470–472.
Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. 2005;81:309–314.
Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009;360:784–789.
784.7 Epistaxis

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