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3.08 Epistaxis (Nosebleed)


Presentation

A 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:

What not to do:

Discussion

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 precipitating cause.

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.

References:


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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Craig Feied, MD
Mark Smith, MD
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