1. Epistaxis
Christina Stapelfeld
NU 870 Spring 2016

2. Diagnosis:
Epistaxis is defined by bleeding from the nose, either anteriorly or posteriorly.
Diagnosis is made based on observation of the patient with a nosebleed.

3. Pathology:
Anterior Epistaxis: Bleeding from Little’s area, an anterior portion of the nose. This area is where the Kiesselbach plexus is located. It contains the majority of blood vessels in the nose. Anterior bleeds are venous in nature; “oozing” blood. Occurs 90% of the time.
Posterior Epistaxis: Arterial in nature. Involves the internal maxillary arteries. Characteristic of more forceful bleeding. Occurs only 10% of the time.

4. Pathology cont.

5. Causes:
Nasal Trauma: nose picking, forceful nose blowing, foreign body
Severe drying: rhinitis, low humidity, supplemental oxygen
Underlying conditions: hypertension, deviated septum, atherosclerotic disease, cocaine or alcohol abuse

6. HPI & PMH Amount of blood, duration, frequency
ROS: Head, Eyes, Ears, Nose, Throat, & Respiratory system for symptoms of distress
History of allergies? Hypertension? Atherosclerosis? Previous episodes of epistaxis? Easy bruising? Hematuria? Melena? Heavy menses?

7. Medication, Surgical, & Family HX
Medications: anticoagulants? NSAIDS? Salicylates? To rule out toxicity
Surgery: Ears? Nose? Throat? i.e. sinuses, nasal deviation, tonsillectomy, and/or adenoids
Family Hx: Osler-Weber-Rendu syndrome- hereditary syndrome which affects blood vessels throughout the body causing unexplained bleeding
Hemophilia

8. Social History Alcohol and Drug Use Allergens
Is living space humidified?

9. Physical Exam:
The physical exam should include the head, eyes, ears, nose, & throat- is there a patent airway?
Respiratory system until the source of bleeding is identified
Skin for rash including petechia and bruising- internal bleeding?
Lymph nodes and surround tissues for anything suggestive of a tumor or malignancy

10. Diagnostic Testing
Patients who are suspected for bleeding and who are taking anticoagulant medications should have labs drawn for protime and platelet count
If this is a reoccurring issue, sinus imaging should be ordered- typically ENT
When a cause cannot be identified, genetic testing as well as further testing for tumors can be ordered through a specialist

11. Differentials Allergic Rhinitis Medication toxicity Cocaine use
Osler-Weber- Rendu syndrome
Foreign body

12. Red Flags Inability to stop bleeding Airway obstruction
Signs of hypovolemic shock
Multiple reoccurrences without a known cause

13. Treatment
Direct pressure by compression of the nares for fifteen minutes with the patient sitting and leaning forward
Combination topical decongestant and antihistamine to stop the bleeding- Afrin
Cauterization with silver nitrate when the source of bleeding can be identified
Nasal Tamponade or anterior packing for no less that 5 days when the source of bleeding cannot be identified
NasalCEASE- Calcium Alginate product found OTC – causes coagulation via platelet aggregation

14. Nasal Tamponade

15. Anterior Nasal Packing

16. NasalCEASE

17. Teaching Avoid exercise and straining for several days
Avoid nasal trauma
Moisturize nasal mucosa with water based lubricants
Humidify living space
Nasal packing should be moisturized with saline several times a day
First aid and how to stop future nose bleeds
When to seek medical attention

18. Referral, Follow-Up, & Outcome
Immediate referral to ER for bleeding that cannot be stopped or an active posterior bleed is suspected.
Recurrent or large bleeds should be referred to an ENT for further testing
Follow up with PCP in 2-4 weeks to assess for recurrence and sooner if bleeding continues or packing needs to be removed
The desired outcome for epistaxis is to stop the bleeding and treat the cause in recurring situations

19. References:
Barnes, M., Spielmann, P., & White, P. (2012). Epistaxis: A Contemporary Evidence Based Approach. Otolaryngologic Clinics of North America, 45(5), Retrieved January 30, 2016.
Goroll, A. H., & Mulley, A. G. (2014). Primary Care Medicine (7th ed.). Philadelpia, PA: Wolters Kluwer Health.
Nguyen, Q. (2015, January 24). Epistaxis Treatment & Management. Retrieved January 30, 2016, from