INDEX

    Epistaxis – Diagnosis

    Cardinal Presentations / Presenting Problems, Ears, Eyes, Nose, and Throat, Hematological / Oncological

    Last Updated Aug 04, 2020
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    Context

    • 6% of adults require treatment for a nosebleed in their lifetime.
    • Bimodal age distribution: 2-10 years and 50-80 years.
    • Etiology is 85% idiopathic:
      • Regional factors:
        • Trauma (finger, FB, NG tube insertion).
        • Nasal dryness and irritation (cold air, supplemental O2, rhinitis).
        • Topical nasal medications (corticosteroids and antihistamines).
        • Drugs (inhalants, cocaine).
        • Nasopharyngeal neoplasm.
      • Systemic risk factors and/or exacerbators:
        • Coagulopathies (acquired or inherited).
        • Anticoagulants and antiplatelets.
        • Alcohol use disorder.
        • Vascular abnormalities (i.e. hereditary hemorrhagic telangiectasia).
        • Hypertension (uncertain association, may prolong bleeding).
        • Congestive heart failure.
    • Source of bleeding:

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    • Approach focuses on:
      • Severity of bleeding:
        • Hemodynamic stability.
        • Initial hemostasis.
      • Identifying the source of bleeding.
      • Consider red flag diagnoses:
        • Anticoagulated patient with supratherapeutic INR.
        • Nasopharyngeal neoplasm.
        • Posterior bleed secondary to carotid artery aneurysm.

    Diagnostic Process

    1. Assess airway compromise and hemodynamic stability
    • Secure airway,
    • IV fluid resuscitation,
    • emergency ENT consult if needed

     

    1. History (2):
    • Laterality and severity of bleeding
    • Recurrent epistaxis
    • Contributing factors and triggers (see above)

     

    1. Visualize the source of bleeding

    Pretreatment

    • Topical anesthetic and vasoconstrictor (5)
      • Apply with cotton balls or with rolled cotton pledgets.
      • Several options:
        • Lidocaine (2 or 4%) with oxymetazoline spray (6)
        • LET solution (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%)
        • 4% cocaine hydrochloride (both anesthetic and vasoconstrictive) (3)
      • Apply pressure to attempt initial tamponade
        • Patient may apply pressure for 10-15 minutes OR

     

    If bleeding stops, observe for 30 mins – 1 hour with ambulation, and discharge home with instructions (see PECS – Epistaxis management).

    If bleeding does not resolve:

    • Optimize exposure (1) :
      • Headlight, nasal speculum
      • Clear the nose with blowing and/or suctioning
      • Patient in “sniff” position
    • Inspect:
      • Kiesselbach’s plexus (anterior epistaxis)
      • If no source of bleeding visualized:
        • Either posterior epistaxis or resolving anterior epistaxis
        • Proceed to treatment (see PECS – Epistaxis management)
    1. Investigations

    Labs usually not required unless (3,7):

    • CBC for heavy, recurrent bleeding, or suspected thrombocytopenia
    • INR, PTT
      • taking Warfarin
      • taking DOAC and moderate to severe bleeding secondary to uncontrolled posterior epistaxis (8,9)
      • known hepatic or renal dysfunction
    • Creatinine, if DOAC (renally cleared) and significant bleeding (9)
    • ECG, group and screen, crossmatch if blood loss significant (8).

     

    1. Clinical pitfalls
    • Not investigating recurrent unilateral epistaxis for nasopharyngeal neoplasm
      • CT and/or endoscopy (2)
      • Higher risk if Chinese or South Asian decent
    • Not involving ENT early for severe, refractory hemorrhage.

    Quality Of Evidence?

    Justification

    Established approach to common emergency department presentation.

    High

    Additional Resources

    Related Information

    Reference List

    Relevant Resources

    RELEVANT CLINICAL RESOURCES

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    RELEVANT VIDEO

    02:15

    Epistaxsis Management

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