• 6% of adults require treatment for a nosebleed in their lifetime.
• Bimodal age distribution: 2-10 years and 50-80 years.
• 85% of the time the cause is unclear:
  • 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:

Blood vessels inside the nose. Author: Mbuchko3, CC BY SA 4.0

• 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.

1. Assess airway compromise and hemodynamic stability

• Secure airway,
• IV fluid resuscitation,
• emergency ENT consult if needed

2. History (2):

• Laterality and severity of bleeding
• Recurrent epistaxis
• Contributing factors and triggers (see above)

3. 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

Proper placement of a nose clip. James Heilman, CC BY SA 4.0

Proper placement of a nose clip. James Heilman, CC BY SA 4.0

• 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)

4. 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).

5. 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.

Useful links:

• BC Emergency Physician’s Network, PECS – Epistaxis Treatment in Adults
• ACEP now – Treatment of epistaxis
• ACEP – Approach flow chart (“Dundee” protocol)
• UptoDate – Management and treatment of epistaxis.
• Life In The Fast Lane: Epistaxis
• Epistaxis management in the Emergency Department (ALiEM)

Patient resources:

• UpToDate: The Basics
• UpToDate: Beyond The Basics

1. McGinnis HD. Chapter 244: Nose and Sinuses. In:  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e [Internet]. New York, NY; [cited 2019 Dec 17]

   
   

2. Schlosser RJ. Epistaxis. N Engl J Med [Internet]. 2009 Feb 19 [cited 2019 Dec 17];360(8):784–9.

   
   

3. Approach to the adult with epistaxis – UpToDate [Internet]. Uptodate. 2019 [cited 2019 Dec 18].

   
   

4. Guthrie K. A Case of Epistaxis [Internet]. Life In The Fast Lane. 2019.

   
   

5. American College of Emergency Physicians. Treatment of epistaxis [Internet]. ACEP Now. 2009 [cited 2019 Dec 18].

   
   

6. Groudine SB, Hollinger I, Jones J, DeBouno BA, Fisher DM. New York State guidelines on the topical use of phenylephrine in the operating room. The Phenylephrine Advisory Committee. Anesthesiology [Internet]. 2000 Mar [cited 2019 Dec 18];92(3):859–64.

   
   

7. Awan MS, Iqbal M, Imam SZ. Epistaxis: when are coagulation studies justified? Emerg Med J [Internet]. 2008 Mar 1 [cited 2019 Dec 17];25(3):156–7.

   
   

8. Canadian Associated of Emergency Physicians. Urgent Oral Anticoagulant Reversal – CAEP [Internet]. [cited 2020 May 4].

   
   

9. UpToDate. Management of bleeding in patients receiving direct oral anticoagulants [Internet]. 2020 [cited 2020 May 4].