Management of

Epistaxis
 Epistaxis -
Introduction
One of the most frequent causes of
bleeding.
Most of the time, bleeding is self-limited,
but can often be serious and life-
threatening.
Epistaxis should never be treated as a
harmless event.
 Local Causes of

Epistaxis
Nasal trauma (nose Bleeding polyp of the

picking, foreign bodies, septum or lateral nasal
forceful nose blowing) wall (inverted papilloma)
Allergic, chronic or
Neoplasms of the nose
infectious rhinitis
or sinuses
Chemical irritants
Tumors of the
Medications (topical)
nasopharynx especially
Drying of the nasal
Nasopharyngeal
mucosa from low humidity
Angiofibroma
Deviation of nasal septum
Vascular malformation
or septal perforation
 Systemic Causes of
Epistaxis
Systemic arterial Anticoagulants
hypertension (ASA, NSAIDS)
Endocrine Causes: Hepatic disease
pregnancy, Blood diseases and
pheochromocytoma coagulopathies such
Hereditary as
hemorrhagic Thrombocytopenia,
telangectasias ITP, Leukemia,
 Hemophilia
Most Common Causes
of Epistaxis
Disruption of the nasal mucosa - local
trauma, dry environment, forceful
blowing, etc

Intranasal medications or recreational

drugs
Hypertension and/or arteriosclerosis
Anticoagulant medications
 Nasal Blood Supply
Internal and external carotid arteries
Many arterial and venous anastomoses
Kiesselbach’s plexus (Little’s area) in anterior
septum
Woodruff’s plexus in posterior septum
Nasal Septal Blood
Supply
Vascula
r anatomy of
the medial
and

lateral
nasal
walls
 The Basics

Epistaxis

History Physical Exam Treatment Plan

 Patient History
Previous bleeding episodes
Nasal trauma
Family history of bleeding
Hypertension current medications and how
tightly controlled
Hepatic diseases
Use of anticoagulants
Other medical conditions.
Types of Nosebleeds
ANTERIOR
Most common in younger population
Usually due to nasal mucosal dryness
Usually controlled with conservative
measures
Types of Nosebleeds
POSTERIOR
Usually occurs in older population
HTN and atherosclerosis are common
contributing factors
May also have deviation of nasal septum
Significant bleeding in posterior pharynx
More challenging to control
 Physical Exam
Vital Sign

IDENTIFY THE BLEEDING SOURCE

Labs
Position and prepare patient
Equipment
Anatomy
 Physical Exam -
Equipment
Protective equipment - gloves, safety
goggles
Headlight if available
Nasal Speculum
Suction with Frazier tip
Bayonet forceps
Tongue depressor
Vasoconstricting agent (such as
oxymetazoline)
Topical anesthetic
Vitals and Labs
Airway #1
Blood Pressure
CIRCULATION
PT/INR
PTT
Position and Prepare
Sit patient up
Universal precautions
Have patient blow nose
Always keep patient either
straight up or slightly
forward
 Equipment
Headlight (ideal)
Nasal Speculum
Afrin or Afrin/Pontocaine solution (1:1)
Silver Nitrate sticks
Nasal tampon
Nasal balloon
Extras
Headlight
Nasal Speculum
Silver Nitrate
Nasal Tampons
Nasal Balloons
 Helpful Extras

Bayonet Forceps
Frazier suction
Tongue Depressors
 Physical Exam
Must evacuate clots first!
Anterior or Posterior
Areas that have stopped
will show up as a small
red spot on the mucosa
May have large clot in
oropharynx
 Nasal Anatomy
Anteriorly
Kesselbachs Plexus

Posteriorly
Sphenopalatine
Complex
Inferior Turbinates
Septum
 Treatment for Anterior
Bleed

Use topical vasoconstrictor and hold

pressure for 15 minutes.

Localized digital pressure for minimum

of 5-10 minutes, perhaps up to 20
Treatment for Anterior
Bleed
If still bleeding and area
identifiable, cauterize with silver
nitrate.
Silver nitrate cautery - avoid cautery of
bilateral nasal septum as this may lead
to necrosis and perforation of the
septum
After cautery, hold pressure again
for 10-15 minutes.
Correct direction for
placement of nasal
packing
Treatment for Anterior
Bleed

If still bleeding…..
 Other Anterior Nasal
Packs
Formed expandable
sponges are very
effective
Formed expandable
sponges are very
effective
Available in many
shapes, sizes and
some are
impregnated with
antibacterial
properties

Treatment for Anterior
Bleed
And, if still
bleeding…….

Wait after pack

placed
10 minutes
 Traditional Anterior
Pack

Usually, 1/2 inch Iodiform or NuGauze is used.

Coat the gauze with a topical antibiotic ointment prior to placement.
 Treatment for Posterior
Bleed
Usually after a short anterior pack has been
placed with no identified location.
Most anterior packs will cover both sites, so it
is better to use a longer tampon or balloon.
Balloon device is most often successful
Rarely place a true posterior pack
Traditional Posterior
Pack
 After Care
Arrange follow up
within 2-3 days for
pack removal
Light activity only
Anti Staph antibiotics
(Toxic Shock)
Questions?