1. JAGDEEP DOULLA PGY-2 FAMILY MEDICINE PRIMROSE FAMILY HEALTH CENTER Epistaxis

2. Outline Epidemiology Anatomy Case Diagnosis Anterior Bleed Management Posterior Bleed Management References

3. History 60% of individuals worldwide will get a nose bleed in their lifetime Average age of patients presenting to FD or ED  Children <10 years old  Adults > 35 years old

4. Anterior Circulation External carotid  facial artery and sphenopalatine artery Internal carotid  anterior and posterior ethmoidal arteries 90% bleeds at Kiesselbach’s Area Nasal Septum

5. Posterior Circulation External Carotid  sphenopalatine branch of the internal maxillary artery Common in older patients  >64 years old Lateral Nasal Wall

6. Common is Common

7. Case 65 yo male presents with right sided epistaxis  Hx of HTN  Medications  Atenolol  ASA

8. Patient Evaluation Ensure patent airway Hemodynamic stability History  Duration  Frequency  Severity  Inciting factors  Family hx of bleeding problems

9. Diagnosis Common Causes  Chronic Sinusitis  Epistaxis Digitorum  Foreign Bodies  Neoplasms & Polyps  Irritants  Medications – topics steroids  Rhinitis  Septal deviation  Septal perforation  Trauma  Vascular malformations or telangiectasia's Systemic Causes  Hemophilia  Hypertension  Leukemia  Liver disease – cirrhosis  Medications  ASA  Anticoagulants  NSAID’s  Platelet dysfunction  Thrombocytopenia

10. Approach to Anterior Bleed Lidocaine with phenylephrine spray to help examine and slow down some of the bleeding  If available cocaine can be used Septal Pressure for 5-20 min Anterior Packing  Cotton swabs  Ribbon gauze impregnated with petroleum jelly  Nonadherent gauze Chemical Cautery  Silver nitrate Electric Cautery

11. Anterior Packing

12. Approach to Posterior Bleed Posterior Packing  Usually required in older individuals taking blood thinners If you can visualize the bleed Chemical Cautery  Silver nitrate Electric Cautery

13. Posterior Packing

14. References Kucik, CJ., Clenny, T. 2005. Management of Eppistaxis. AAFP (71) pg 305-311. Schlosser, RJ. 2009. Epistaxis. New England Journal of Medicine 360(8) pg 784-789.