epistaxis (nose bleed)
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Introduction
Generally a benign condition related to disruption of Kiesselbach's plexus.
Etiology
- trauma
- self-inflicted
- digital manipulation
- vigorous blowing
- vigorous wiping
- septal perforation
- external nasal trauma
- self-inflicted
- inflammation
- infection
- vascular disorders
- coagulation disorders
- tumors
- benign tumors
- hemangioma
- juvenile nasopharyngeal angiofibroma
- meningioma
- cancer
- benign tumors
- miscellaneous disorders
- decreased environmental humidity
- atrophic rhinitis
- vicarious menstruation
- chemical irritation
- septal deformity
- hypertension is a risk factor[6]
Pathology
- 90% arise in the anterior nasal septum
- posterior epistaxis more likely to result in serious hemorrage
Clinical manifestations
- visible blood in the oropharynx does not confirm posterior epistaxis
Laboratory
- minor & not recurrent problem
- no laboratory testing indicated
- refractory or recurrent epistaxis
Diagnostic procedures
Management
- general considerations/strategy
- most episodes are self limited
- anterior nasal packing for severe acute epistaxis in anticoagulated patient[9]
- clear nose of blood & clot with suction
- compress with direct pressure to the nasal septal area for at least 5 minutes[5] (15-20 minutes)
- apply topical vasoconstricting agent & anesthetic for 5-10 minutes if direct pressure is unsuccessful
- 4% cocaine (vasoconstriction & anesthesia)
- oxymetazoline
- cotton ball soaked in phenylephrine 1%/lidocaine 4%
- NosebleedQR applied to bleeding nasal mucosa
- nasal packing for persistent epistaxis despite compression[5]
- use resorbable packing if anticoagulant or antiplatelet agent
- anterior nasal packing for severe acute epistaxis in anticoagulated patient[9]
- anterior rhinoscopy to identify the source of the bleeding after removing blood clots
- nasal endoscopy for recurrent bleeding
- topical vasoconstrictors, nasal cautery, or moisturizing or lubricating agents after bleeding site identified[5]
- most episodes are self limited
- anterior epistaxis
- anterior nasal packing for severe acute epistaxis in anticoagulated patient[9]
- cauterize with diathermy if general strategy unsuccessful
- do not cauterize both sides of the nasal septum, this may lead to septal perforation
- pack nose unilaterally if unsuccessful
- pack nose bilaterally with gauze if unsuccessful
- topical application of tranexamic acid (for injection) more effective than anterior nasal packing[4]
- surgical intervention if unsuccessful
- posterior epistaxis
- admit patient to hospital if compression & vasoconstriction unsuccessful
- pack nose unilaterally if unsuccessful
- consider diathermy with endoscopic guidance
- pack nose unilaterally with balloon catheter
- foley catheter # 12 or 13 french with 30 mL balloon
- intervene surgically
- cauterize, arterial ligation, endovascular embolization
- premarin vaginal cream may be useful[2]
- discharge instructions
- vasoconstricting sprays for 2-3 days
- phenylephrine spray
- oxymetazoline
- do not blow wipe or pick nose
- no heavy lifting, straining, or exertion
- saline nasal sprays PRN
- humidified environment
- vasoconstricting sprays for 2-3 days
More general terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 46-48
- ↑ 2.0 2.1 Prescriber's Letter 13(10): 2006 Alternative or 'Off-label' Routes of Drug Administration Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=221012&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 3.0 3.1 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 18. American College of Physicians, Philadelphia 2009, 2012, 2018.
Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009 Feb 19;360(8):784-9 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19228621 - ↑ 4.0 4.1 Zahed R, Mousavi Jazayeri MH et al Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med. 2017 Nov 10. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29125679
- ↑ 5.0 5.1 5.2 5.3 Tunkel DE, Anne S, Payne SC et al Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary Otolaryngology. Hea & Neck Surgery, Jan 7, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31910122 https://journals.sagepub.com/doi/full/10.1177/0194599819889955
Tunkel DE, Anne S, Payne SC Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020 Jan;162(1_suppl):S1-S38. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31910111
Tunkel DE, Holdsworth SM, Alikhaani JD, Monjur TM, Satterfield L. Plain Language Summary: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020 Jan;162(1):26-32. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31910124 - ↑ 6.0 6.1 Byun H, Chung JH, Lee SH et al Association of Hypertension With the Risk and Severity of Epistaxis. JAMA Otolaryngol Head Neck Surg. Sept 10, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32910190 https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2770570
- ↑ Rothaus C Epistaxis. NEJM Resident 360. Mar 10, 2021 https://resident360.nejm.org/clinical-pearls/epistaxis
- ↑ Kasle DA, Fujita K, Manes RP Review of Clinical Practice Guideline: Nosebleed (Epistaxis). JAMA Surg. Published online July 7, 2021 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34232284 https://jamanetwork.com/journals/jamasurgery/fullarticle/2781752
- ↑ 9.0 9.1 9.2 9.3 NEJM Knowledge+ Otolaryngology
Seikaly H. Epistaxis. N Engl J Med. 2021 Mar 11;384(10):944-951. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33704939 Review. https://www.nejm.org/doi/pdf/10.1056/NEJMcp2019344