3.08 Epistaxis (Nosebleed)
PresentationA patient generally arrives in the emergency department with
active bleeding from his nose or spitting up blood that is draining into
his throat. There may or may not be a report of minor trauma such as
sneezing, nose blowing or nasal manipulation. On occasion the
hemorrhage has stopped but the patient is concerned because the
bleeding has been recurring over the past few hours or days. Bleeding is
most commonly visualized on the anterior aspect of the nasal septum
within Kiesselbach's plexus. The anterior end of the inferior turbinate is
another site where bleeding can be seen. Often, especially with posterior
hemorrhaging, a specific bleeding site cannot be discerned.
What to do:
- If significant blood loss is suspected, gain vascular access and
administer crystalloid intravenous solution.
- Have the patient maintain compression on the nostrils by pinching
with a gauze sponge while you assemble all equipment and supplies at
the bedside. Inform the patient that you will be controlling the bleeding
in a stepwise fashion.
- Have the patient sit upright (unless hypotensive) Sedate the patient if
necessary with a mild tranquilizer such as hydroxyzine (Vistaril) or
midazolam (Versed). Cover the patient and yourself to protect your
clothes. Wear gloves.
- Prepare 5 ml of 4% cocaine solution or a 1:1 mixture of tetracaine
2% (Pontocaine) for local anesthesia and epinephrine 1:1000 or
pseudophedrine 1% (Neo-Synephrine) for vasoconstriction.
- Form two elongated cotton pledgets and soak them in the solution.
- Use a bright headlight or head mirror to free up hour hands and help
insure good visualization.
- Have the patient blow the clots from his nose and quickly inspect for
a bleeding site using a nasal speculum and Frazier suction tip. Clear
out any additional clots or foreign bodies.
- Insert the medicated cotton pledgets as far back as possible into both
- Have the patient relax with the pledgets in place for approximately
5-10 minutes. You may use this lull to ask the patient about any past
history of nosebleeds or other bleeding problems, the pattern of this
nosebleed, which side the bleeding seems to be coming from, any
aspirin or blood thinning medication, and any significant medical or
- In the vast majority of cases, active bleeding will stop with this
treatment. The cotton pledgets can be removed and the nasal cavity can
be inspected using a nasal speculum and head lamp. If bleeding
continues, insert another pair of medicated cotton pledgets.
- If the bleeding point can be located, cauterize a l cm area of mucosa
around the bleeding site with a silver nitrate stick and then cauterize the
site itself. Observe the patient for 15 minutes. If this stops the bleeding,
cover the cauterized area with antibiotic ointment and instruct the
patient in prevention (avoid picking the nose, bending over, sneezing,
and straining) and treatment of recurrences (compress below the bridge
of the nose with thumb and finger for five minutes).
- If the bleeding point cannot be located or if bleeding continues after
cauterization, insert an anterior pack. The best is a 1 cm by 10 cm stick
of compressed cellulose which expands to conform (Merocel, Rhino
Rocket). To prevent putrification of the pack, partly cover it with
antibiotic ointment before insertion. Leave some cellulose exposed to
allow for water absorption. Instill a few drops of saline if it does not
- An alternative anterior pack can be made from up to six feet of
half-inch ribbon gauze impregnated with petroleum jelly (Vaseline).
Cover the gauze with antibiotic ointment and insert it with bayonet
forceps. Start with 3-4 plies layered accordian fashion on the floor of
the nasal cavity, placing it as far posteriorly as possible, and pressing it
down firmly with each subsequent layer. Continue inserting the gauze
until the affected nasal cavity is tightly filled (expect to use about 3 to 5
feet per nostril). If unilateral anterior nasal packing does not provide
enough pressure, packing the opposite side of the nose anteriorly can
sometimes increase the pressure by preventing the septum from bowing
over into the side of the nose that is not packed.
- Observe the patient for 15 minutes. If no further bleeding occurs in
the nares or the posterior oropharynx, discharge him on a broad
spectrum antibiotic (amoxicillin tid 250mg) for five days to help prevent
a secondary sinusitis. The packing should be removed in 2-4 days.
- Tape a small folded gauze pad beneath the nose to catch any minor
drainage. The patient can replace this from time to time if necessary.
- Instruct the patient against sneezing with his mouth closed, bending
over, straining, or nose picking. The patient's head should be kept
elevated for 24-48 hours. Provide detailed printed instructions on home
- If the hemorrhage is suspected to have been severe, obtain orthostatic
blood pressure and pulse recordings along with an hematocrit before
making a disposition for the patient.
- If the hemorrhage does not stop after adequate packing anteriorly,
then one or two posterior packs or nasal balloons should be inserted,
and the patient should be admitted to the hospital under the care of an
What not to do:
- Do not waste time trying to locate a bleeding site while brisk
bleeding obscures your vision in spite of vigorous suctioning. Have the
patient blow out any clots and insert the medicated cotton pledgets.
- Do not get routine clotting studies unless there is other evidence of an
underlying bleeding disorder.
- Do not cauterize or use instruments within the nose before providing
adequate topical anesthesia (some initial blind suctioning may, however,
be required to clear the nose of clots before instilling anesthetics).
- Do not discharge a patient as soon as the bleeding stops, but keep him
in the ED for 15-30 minutes more. Look behind the uvula. If it is
dripping blood, the bleeding has not been controlled adequately.
Posterior epistaxis typically stops and starts cyclically and may not be
recognized until all the above treatments have failed.
Nosebleeds are more common in winter, no doubt reflecting the
low ambient humidity indoors and outdoors and the increased incidence
of upper respiratory tract infections. Troublesome nosebleeds are more
common in middle-aged and elderly patients. Causes are numerous:
dry nasal mucosa, nose picking and vascular fragility are the most
common, but others include foreign bodies, blood dyscrasias, nasal or
sinus neoplasm or infection, septal deformity, atrophic rhinitis,
hereditary hemorrhagic telaniectasis and angiofibroma. High blood
pressure makes epistaxis difficult to control but is rarely the sole
Drying and crusting of the bleeding site, along with nose
picking, may result in recurrent nasal hemorrhage. It may be helpful to
instruct the patient on gently inserting Vaseline onto his nasal septum
once or twice a day to prevent future drying and bleeding. Other useful
techniques include electrocautery down a metal suction catheter,
ophthalmic electrocautery tips (see subungual hematoma), submucosal
injection of lidocaine with epinephrine, and application of hemostatic
collagen (Gelfoam). There are also several balloon devices to provide
anterior and posterior tamponade, some with a channel to maintain a
patent nares. Because of the nasopulmonary reflex, arterial oxygen
pressure will drop about 15mmHg after the nose is packed, which can
be troublesome in a patient with heart or lung disease, and usually
requires hospitalization and supplemental oxygen.
- Viducich RA, Blanda MP, Gerson LW: Posterior epistaxis: clinical features and acute complications. Ann Emerg Med 1995;25:592-596.
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD