Epistaxis (nosebleeds) is one of the most common ear, nose, and throat (ENT) emergencies that present to the emergency room or primary care. There are two types of nosebleeds: anterior (more common), and posterior (less common, but more likely to require medical attention). The source of 90% of anterior nosebleeds within the Kiesselbach plexus (also known as Little’s area) on the anterior nasal septum. The sphenopalatine artery (SPA) is the most probable source for posterior bleeds. 
Nosebleeds can be divided into primary or secondary. Primary nosebleeds are idiopathic and spontaneous. Secondary bleeds have clear and definite causes like trauma or anticoagulation use.
There are multiple causes of epistaxis which can be divided into local, systemic, environmental, and medication induced. Local causes can include digital manipulation, a deviated septum, trauma, inhaled corticosteroids, and chronic nasal cannula use. Systemic causes can include alcoholism, hypertension, vascular malformations, or coagulopathies (von Willebrand disease, hemophilia). Environmental factors can include allergies or dryness during winter months. Medications include NSAIDS (ibuprofen), anticoagulants (warfarin), platelet aggregation inhibitors (clopidogrel), or supplement/alternative medications. It is important to consider other etiologies/malignancies if the patient has red flags such as unilateral nasal blockage, facial pain, headaches, or facial deformity. Drug use (cocaine) use should be considered in adolescent patients.
Nosebleeds are rarely fatal, accounting for only four of the 2.4 million deaths in the United States. About 60% of people have experienced a nosebleed during their life, and only 10% of nosebleeds are serious and warrant treatment/medical intervention. They occur most commonly in children ranging from 2 to 10 years old and the elderly ranging from 50 to 80 years old.
Nosebleeds are caused by the rupture of a blood vessel within the nasal mucosa. Rupture can be spontaneous, initiated by trauma, use of certain medication, and/or secondary to other comorbidities or malignancies. An increase in the patient's blood pressure can increase the length of the episode. Anticoagulant medications, as well as clotting disorders, can also increase the bleeding time.
Most nosebleeds occur in the anterior part of the nose which has a lot of blood vessels (Kiesselbach's plexus). This region is also known as Little's area.
Bleeding from the back of the nose is known as a posterior bleed. This is usually due to bleeding from Woodruff's plexus. These are often difficult to control and are associated with bleeding from both nostrils. It can generate a greater flow of blood into the posterior pharynx and have a higher risk for airway compromise or aspiration due to increased difficulty in controlled the bleed.
The history should include duration, severity, frequency, laterality of the bleeds, cause, and interventions provided prior to seeking care. In regards to medication use, be sure to ask about anticoagulant, aspirin, or NSAID use. Include family history of coagulopathies and relevant history. Ask of any drug or alcohol use.
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, cotton pledgets, and anesthetic available. 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.
Differentiating an anterior or posterior is key in management. Diagnosis of anterior bleeding is can be made by direct visualization using a nasal speculum and light source. A topical spray with anesthetic and epinephrine may be helpful for vasoconstriction to help control bleeding and to aid in visualization of the source. Usually, diagnosis of posterior bleeding is made after measures to control anterior bleeding have failed. Clinical features of posterior bleeding can include bleeding in the elderly with either inherited or acquired coagulopathy, hemorrhage from bilateral nares, or significant blood noted in the posterior nasopharynx. Labs may be obtained if necessary, including a complete blood cell count (CBC), type and cross match, and coagulation studies. Occasionally, imaging such as x-ray or a CT may also be needed.
Start with a primary survey and address airway, ensure the airway is patent. Next, assess for hemodynamic compromise. Obtain large bore intravenous access in patients with severe bleeding and obtain labs. Reverse blood clotting as necessary, if concern with medication use.
Treatment for anterior bleeding can be started with direct pressure. Have the patient apply constant direct pressure by pinching the nose over the cartilaginous tip (instead of over the bony areas) for a few minutes to try to control the bleed. If that is ineffective, chemical cauterization with silver nitrate, thrombogenic foams or gels, anterior nasal packing, anterior epistaxis balloons, or nasal tampons (Rapid Rhino) may be considered.
If none of this works, the bleeding may be from the posterior nasal cavity. Symptoms can include bleeding from both nostrils or blood present in the posterior pharynx. Posterior nasal packing may be used as a temporary measure while waiting for ENT consult. It is associated with higher rates of complications like pressure necrosis, infection or hypoxia. Foley catheters can be used by experienced personnel to tamponade a posterior bleed. Other options for uncontrolled bleeding include external artery, internal maxillary artery or sphenopalatine artery ligation, with sphenopalatine artery ligation being widely used. Angiographic embolization of the bleeding vessel is an alternative for sphenopalatine artery ligation for patients who are unfit for general anesthesia or who have failed a prior sphenopalatine artery ligation.
Patients with anterior nosebleeds can be discharged if the bleeding is controlled and hemodynamic stability is observed for at least one hour in the Emergency Department (ED). Follow up with ENT should occur within 48 hours. If non-biodegradable packing is used, patients should return to the ED or ENT for packing removal in two to three days. If a patient, including pediatric patients, require posterior packing, admission may be warranted to monitor for complications. Patients on warfarin can continue using it if INR levels are within desired range, NSAIDs should be discontinued for three to four days.
Application of a topical ointment to the nasal mucosa to ensure moisturisation of the nasal mucosa for a few days can help to prevent recurrent epistaxis. Patients should also be advised to avoid hot foods, strenuous activity, blowing nose, or digital manipulation of the nose on discharge.
The majority of patients with a nose bleed present to the emergency department. While most anterior nosebleeds can be arrested with digital pressure, a follow-up appointment is recommended in patients with repeat episodes. Nasal packing is another option but the packing must be removed in 24-48 hours. Drug-induced nosebleeds may require reversal of the INR and admission. In rare cases, embolization or cauterization may be required to stop a nose bleed. The outcomes for more patients with nose bleeds is good.
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