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    Epistaxis – Diagnosis

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

    Last Updated Aug 04, 2020
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    • 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.

    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


    • 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)
    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?


    Established approach to common emergency department presentation.


    Additional Resources

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