Epistaxis (“nose bleed”) is one of the most common ENT complaints seen in the ED. It occurs in up to 60% of the population, and one in ten people affected seek medical attention for the complaint(1). The condition can be classified as anterior or posterior, determined by the anatomic site of bleeding. Around 90% of all cases arise from the anterior nasal septum at the Kiesselbach’s plexus, a confluence of terminal branches of internal and external carotid arteries. Posterior epistaxis occurs from injury to deeper structures in the nose and can be more difficult to manage due to potential arterial involvement and may present a greater risk of aspiration and challenge in achieving hemostasis (1,2).
Points to focus upon
- Location of bleeding (right or left nare)
- Estimated quantity of bleeding
- Previous bleeding episodes and treatment
- Co-morbid conditions
- Medications (Especially anticoagulants /anti-platelets)
Prior to any evaluation, make sure to don proper personal protective equipment including eye shield.
Have the patient forcefully blow out any residual clot from the nose to allow for proper visualization.
Use a proper light source and a nasal speculum (if your site has one) to attempt to visualize any active bleeding.
Be concerned for a posterior location of the bleed if you are unable to visualize an anterior source with continued epistaxis, bilateral bleeding, or significant blood in the posterior oropharynx
Evidence of clinical instability (tachycardia, hypotension, airway compromise, respiratory distress, or altered mental status) requires prompt intervention. Hemodynamic stabilization and airway management are should take priority in a critical patient.
The following is listed as a stepwise management flow. After any step, if hemostasis is maintained for 2-3 hours in the ED the patient may be discharged with appropriate follow up and return precautions.
- Have the patient forcefully blow out any residual clot from the nose to allow for proper visualization.
- Direct pressure, direct pressure, more direct pressure
- Instruct the patient to pinch the nasal cartilage directly below the nasal bone for around 10 minutes
- Instil Oxymetazoline to assist with nasal vasoconstriction if initial compression is ineffective
- Direct cautery with silver nitrate sticks if the specific area of bleeding can be visualized
- Do not perform if bleeding can be directly visualized
- Avoid cautery on bilateral sides of the nasal septum to prevent septal ischemia
- Anterior nasal packing
- Insert directly posteriorly and avoid pushing the product superiorly
- Foam or gel-based product (ex “Merocel”)
- Balloon tamponade product (ex “Rhino-rocket”)
- With or without TXA
- If these interventions do not work have high clinical suspicion for a posterior location of the bleeding
- Depending on your institution, early ENT consult may be warranted for potential surgical repair
- Some commercial products are available for posterior packing that are much longer in length
- If unavailable, insert a Foley catheter through the nose into the posterior nasopharynx.
- Inflate the balloon and administer gentle traction. Secure in place.
- Patients with posterior packing or those that require bilateral nasal packing should be admitted for airway and hemodynamic monitoring with ENT consult.
Laboratory evaluation is typically unnecessary for uncomplicated cases. However, if there is concern for hemodynamic instability, or the patient is currently taking anticoagulant medications, labs including CBC and a coagulation panel are warranted.
Hypertension and Epistaxis
There has been a long controversy regarding the association of hypertension and the incidence and severity of epistaxis. However, definitive evidence identifying a causal relationship has not been identified (3). Additionally, no strong evidence has been discovered that supports acute blood pressure control in the ED management of epistaxis, and routine administration of antihypertensives is not recommended (2).
Historically, oral antibiotics have been prescribed prophylactically to patients with anterior packing due to a concern for toxic shock syndrome. However, recent updates suggest that prophylactic antibiotic use for nasal packing in spontaneous epistaxis patients is not necessary. However, antibiotics should be considered in patients with significant co-morbidities, immunocompromised status, or placement of posterior packing(4,5). Discuss the risks and benefits of antibiotics with patient prior to prescribing.
Gauze or tamponade devices can be soaked in TXA (tranexamic acid) prior to application to assist with hemostatic control. Topical TXA has demonstrated benefit in the management of epistaxis, including decreased time to hemostasis, and lower ED length of stay(6,7).
Recommended readings, videos, and podcasts
- CRACKCast E072: Otolaryngology
- EM Cases: ENT Emergencies Pearls, Pitfalls, Tips and Tricks
- EMDocs: Epistaxis