Definition
A.Epistaxis is a nosebleed or hemorrhage from the nose.
Incidence
A.Nosebleeds occur in approximately 60% of Americans at least once in a lifetime. However, fewer than 10% will seek medical care for a nosebleed.
Pathogenesis
A.Epistaxis is caused by disruption of the nasal mucosa. More than 90% of nosebleeds are related to local irritation rather than underlying anatomic lesions and are self-limiting. Most start in the anterior nasal cavity (Kisselbach’s plexus).
B.Posterior nasal bleeding usually originates from the turbinates or lateral nasal wall.
C.Nosebleed more commonly occurs during the winter months. It is commonly associated with other conditions such as upper respiratory infections (URIs), allergic rhinitis, or mucosal changes due to other conditions.
Predisposing Factors
A.Local trauma, usually from nose picking.
B.Acute inflammation from a URI (e.g., common cold, acute sinusitis, and allergic rhinitis).
C.Vigorous nose blowing.
D.Inhalation of chemical irritants.
E.Drying and crusting of nasal septum.
F.Trauma.
G.Cocaine use.
H.Pregnancy.
I.Neoplasm.
J.Systemic causes:
1.Bleeding disorders (most common).
2.Hypertension.
3.Arteriosclerosis.
4.Renal disease.
Common Complaints
A.Common complaint is unusually severe or frequent nose-bleeds.
Other Signs and Symptoms
A.Anterior epistaxis:
1.Unilateral.
2.Continuous, moderate bleeding from septum of nose.
B.Posterior epistaxis:
1.Brisk (arterial) bleeding.
2.Blood flowing into pharynx (indicates a more serious problem).
Subjective Data
A.Inquire about amount, duration, and frequency of bleeding. Ask about what side the bleeding started.
B.Ask about use of oral anticoagulants, aspirin, or aspirin-containing compounds (e.g., Pepto-Bismol, aspirin, Excedrin).
C.Ask about recent or current URIs, family history of abnormal bleeding, recent surgery, or trauma.
D.Ask the first day of female patient’s last menstrual period (if appropriate). Determine if the patient is pregnant.
E.Ask about possible foreign body in the nose.
F.Ask about cocaine use or occupational exposure to irritants or chemicals.
G.If the patient has a history of nosebleeds, how did the patient treat previous nosebleeds?
H.Has the patient ever been evaluated for a blood clotting abnormality, such as thrombocytopenia or platelet dysfunction?
I.Does the patient complain of bruising easily, melena, or heavy menstrual periods?
J.Ask about family history of bleeding disorders, such as hemophilia or von Willebrand’s disease.
Physical Examination
A.Check temperature, blood pressure (check for orthostatic hypertension), pulse, and respirations. If nasal packing is required, take precaution and monitor patient closely for vasovagal episode during insertion of nasal packing.
B.Inspect:
1.Check airway patency with patient sitting and leaning forward.
2.Observe skin, mucous membranes, and conjunctiva for rash, pallor, purpura, petechiae, and telangiectasias.
3.Perform full eye exam, noting pupillary response.
4.Examine nose for septal perforation and ulcerations, which indicates cocaine use. Collagen diseases (such as lupus) are occasionally responsible for ulceration. Epistaxis is rare in hemophiliacs without trauma but is characteristic of von Willebrand’s disease.
5.Examine nasal discharge: A unilateral foul discharge with blood indicates a foreign body in the nose.
6.After bleeding has stopped:
a.Inspect nasal mucosa for color, discharge, masses, lesions, and swelling of turbinates.
b.Inspect nasal septum for alignment, septal perforation, and crusting.
C.Auscultate: Auscultate heart and lungs.
D.Palpate: Check for enlarged lymph nodes in the neck to rule out sarcoidosis, tuberculosis, or malignancy.
E.Percuss: Percuss sinuses.
Diagnostic Tests
A.None is required unless the patient has recurrent or severe blood loss.
B.Drug screen, if indicated.
C.Hematocrit and hemoglobin if bleeding is severe.
D.Complete blood count (CBC) with differential.
E.Platelets, prothrombin time (PT), and partial thromboplastin time (PTT) if bleeding disorder is suspected.
F.Sinus films if recurrent sinus pain, tenderness, and bleeding.
Differential Diagnoses
A.Epistaxis.
B.Foreign body.
C.Septal deformity.
D.Perforated nasal septum.
E.Coagulation disorder (von Willebrand’s disease).
F.Nasal tumors.
G.Drug-induced coagulopathy.
H.Hypertension.
I.Pregnancy.
Plan
A.General interventions: Main goal is to control episodes of bleeding.
B. 
See Section III: Patient Teaching Guide Nosebleeds.
C.Pharmaceutical therapy/medical/surgical management:
1.To control anterior septal bleeding:
a.Have patient sit and lean forward, apply pressure to reduce venous pressure, and prevent
swallowing of blood. Apply an ice pack over the dorsum of the nose.
b.Ask patient to blow his or her nose to remove blood clots.
c.Nares can then be sprayed with oxymetazoline (Afrin).
d.Ask patient to squeeze nasal septum and hold for approximately 10 to 15 minutes.
e.If bleeding continues, other treatments to perform include the following:
i.Anesthetize mucous membrane by applying cotton soaked with a vasoconstrictor, lidocaine 2% or lidocaine (Xylocaine) plus topical epinephrine (1:10,000), or cocaine 4% for 10 to 15 minutes.
ii.If bleeding continues, cautery may be used by applying a silver nitrate stick to the bleeding site for no longer than 10 seconds to the prominent vessels, until gray eschar appears. Warn the patient that this procedure is painful.
iii.If bleeding still does not stop (rare), nasal packing may be needed, using a nasal tampon. Apply the topical lidocaine to the mucosa, then cover the nasal tampon with bacitracin ointment and insert the tampon into the nasal cavity until the tampon is inside the cavity. Packing may be expanded by applying saline to the packing with a saline filled syringe. Monitor the patient for vasovagal episode during the insertion of packing.
2.To control posterior septal bleeding:
a.Have the patient sit and lean forward.
b.Control bleeding: Spray nose with topical anesthetic and vasoconstrictor, and apply pressure to bleeding site.
c.Consult a physician. The patient needs emergency room care immediately because of rapid blood loss.
d.Take blood pressure and pulse and order hematocrit; blood type and cross-match may be needed.
Follow-Up
A.Anterior septal bleeding: Referral to otolaryngologist is recommended for unsuccessful cessation of hemorrhage.
B.For posterior nosebleeds, admit the patient to the hospital and refer to an otolaryngologist.
Consultation/Referral
A.Posterior epistaxis: Refer to a physician and/or otolaryngologist immediately.
Individual Considerations
A.Pregnancy:
1.Nosebleeds are common.
2.Suggest use of saline spray to keep mucous membranes moist and use humidifier at bedtime.
3.Follow use of saline spray with Vaseline applied with Q-tip daily to prevent recurrent nosebleeds.
B.Geriatrics:
1.Spontaneous posterior hemorrhage is more common in elderly patients.
2.In the elderly population over 60 years old, epistaxis is classically associated with hypertension, arteriosclerosis, coagulation disorders, chronic anemia, angina pectoris, and cerebral hemorrhages. Be sure to ask if the patient has been prescribed daily aspirin and review education with patient/family regarding the benefits as well as the risks.
3.Airway obstruction from posterior packing is especially risky in elderly.
4.Applying water-based lubricant on rims of nostrils to maintain mucosal moisture may cause lipoid pneumonia in elderly.
5.In postmenopausal women, the basement membrane of the nose becomes thicker and structural atrophy may occur causing nasal mucosa to dry. Assess geriatric women for chronic nasal congestion. If it has become frequent, then it increases the risk of mucosa damage and epistaxis.
6.Although epistaxis with geriatrics may indicate an important underlying serious condition, it might also be a benign incident related to natural aging: inflammation of mucosa, injury (scratching too hard), dryness, or side effect from a medication.