Epistaxis

Epistaxis is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • Nosebleeds are a common emergency presentation accounting for 1 in 200 ED visits
  • Usually minor and self-limited but rarely may be life threatening:
    • Lifetime incidence of ∼60%:
      • Bimodal age distribution with one peak <10 and one peak between the age of 70–79
      • Posterior epistaxis more common in the elderly
      • Male > female
      • Severe bleeds requiring surgical intervention are more common in patients >50 yr
      • Occurs more frequently with low humidity during the winter, in northern climates, and at high altitude
  • The nasal cavity is supplied with blood vessels originating from both the internal and external carotid arteries
  • Location of the hemorrhage determines therapy:
    • Anterior epistaxis (90% of cases): Bleeding can be visualized in anterior nose
      • Most commonly bleeding is located at Kiesselbach plexus, an anastomotic network of vessels on the anteroinferior nasal septum
      • Rarely, bleeding is found on the posterior floor of the nasal cavity or the nasal septum
  • Posterior epistaxis (10% of cases): Bleeding source not within range of direct visualization
    • Posterolateral branch of sphenopalatine artery

Etiology

  • Idiopathic:
    • Dry nasal mucosa (low humidity)
  • Nasal foreign body:
    • Children, mentally retarded patients, psychiatric patients
  • Infection:
    • Rhinosinusitis
    • Nasal diphtheria
    • Nasal mucormycosis
  • Allergic rhinitis
  • Trauma:
    • Nose picking (most common in children)
    • Postoperative
    • Facial trauma
    • Barotrauma
  • Environmental irritants:
    • Ammonia
    • Gasoline
    • Sulfuric acid
    • Glutaraldehyde
  • Intranasal neoplasia: Most commonly papilloma
  • Coagulopathy:
    • Hemophilia A or B
    • von Willebrand disease
    • Thrombocytopenia: Liver disease, leukemia, chemotherapy viral illness, or autoimmune disease
    • Platelet dysfunction: Renal impairment or chronic alcohol consumption
  • Drug induced:
    • Salicylates
    • NSAIDs
    • Anticoagulant medications
  • Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease)
  • Atherosclerosis of nasal vasculature
  • Endometriosis
  • Iatrogenic:
    • Nasogastric tube insertion
    • Nasotracheal intubation
    • Nasal airway placement

-- To view the remaining sections of this topic, please or --

Basics

Description

  • Nosebleeds are a common emergency presentation accounting for 1 in 200 ED visits
  • Usually minor and self-limited but rarely may be life threatening:
    • Lifetime incidence of ∼60%:
      • Bimodal age distribution with one peak <10 and one peak between the age of 70–79
      • Posterior epistaxis more common in the elderly
      • Male > female
      • Severe bleeds requiring surgical intervention are more common in patients >50 yr
      • Occurs more frequently with low humidity during the winter, in northern climates, and at high altitude
  • The nasal cavity is supplied with blood vessels originating from both the internal and external carotid arteries
  • Location of the hemorrhage determines therapy:
    • Anterior epistaxis (90% of cases): Bleeding can be visualized in anterior nose
      • Most commonly bleeding is located at Kiesselbach plexus, an anastomotic network of vessels on the anteroinferior nasal septum
      • Rarely, bleeding is found on the posterior floor of the nasal cavity or the nasal septum
  • Posterior epistaxis (10% of cases): Bleeding source not within range of direct visualization
    • Posterolateral branch of sphenopalatine artery

Etiology

  • Idiopathic:
    • Dry nasal mucosa (low humidity)
  • Nasal foreign body:
    • Children, mentally retarded patients, psychiatric patients
  • Infection:
    • Rhinosinusitis
    • Nasal diphtheria
    • Nasal mucormycosis
  • Allergic rhinitis
  • Trauma:
    • Nose picking (most common in children)
    • Postoperative
    • Facial trauma
    • Barotrauma
  • Environmental irritants:
    • Ammonia
    • Gasoline
    • Sulfuric acid
    • Glutaraldehyde
  • Intranasal neoplasia: Most commonly papilloma
  • Coagulopathy:
    • Hemophilia A or B
    • von Willebrand disease
    • Thrombocytopenia: Liver disease, leukemia, chemotherapy viral illness, or autoimmune disease
    • Platelet dysfunction: Renal impairment or chronic alcohol consumption
  • Drug induced:
    • Salicylates
    • NSAIDs
    • Anticoagulant medications
  • Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease)
  • Atherosclerosis of nasal vasculature
  • Endometriosis
  • Iatrogenic:
    • Nasogastric tube insertion
    • Nasotracheal intubation
    • Nasal airway placement

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