ENT \ Nose Bleeds

Question 1

What is the most common cause of nosebleeds (epistaxis)?

Answer 1

Local trauma caused by nose picking or direct blunt trauma

Question 2

What are some other causes of epistaxis?

Answer 2

• Other trauma (surgery, forceful blowing)
• Chronic irritation (dry air, smoke/pollutants)
• Cocaine use
• Intranasal medications
• Nasal foreign body
• Intranasal polyp or tumor
• Systemic problems: bleeding diathesis, blood thinning medications, hypertension

Question 3

What accompanying symptoms would prompt an evaluation for bleeding disorders?

Answer 3

• Frequent bleeding or bleeding from multiple sites other than just the nose
  
  • excessive bleeding/bruising from minor wounds
  • bleeding gums
  • hematemesis
  • melena
  • menorrhagia
  • history of postpartum bleeding
  • history of excessive bleeding during surgery, etc)

Question 4

What labs would you obtain to start this evaluation?

Answer 4

• Complete blood count
• prothrombin time (PT) and international normalized ratio (INR)
• partial thromboplastin time (PTT)
• peripheral blood smear

Question 5

What is Kiesselbach plexus?

Answer 5

• An area in the anteroinferior part of the nasal septum where several arteries anastomose and is the most frequent area of epistaxis

Question 6

What is the management of a stable patient with a nosebleed?

Answer 6

• Patient should lean forward (avoids posterior blood accumulation)
• blow out clots
• then squeeze cartilaginous nose (steady moderate pressure for 5-20 minutes)
• while you perform history and physical (look for easily reversible cause of bleeding).

Question 7

If initial first aid(lean forwars and apply pressure) does not stop a nose bleed and you confirm an anterior nosebleed with direct visualization, what other steps can you take to stop the bleeding?

Answer 7

• Intranasal oxymetazoline (decongestant) and
• lidocaine (analgesic) phenylephrine
• Cautery with silver nitrate or
• nasal packing

Question 8

If a patient is (nose)bleeding profusely and the nose bleeding is difficult to stop, what kind of bleed (in terms of location) are you most likely dealing with?

Answer 8

Posterior bleed (although anterior bleed is still possible)

Question 9

What management steps should you take for a profusely bleeding nose?

Answer 9

• this is more likely a posterior bleed
• Use universal precautions (eye mask, gown)
• Start large bore IV
• FBC, type and cross
• epistaxis tray
• Tamponade bleed:
  
  • nasal catheter with dual-chambered cuff
  • foley cathete
  • or posterior packing
• Consider ENT referral

Question 10

What are the most worrisome complications from severe acute nosebleeds?

Answer 10

Airway compromise and hemodynamic instability