Epistaxis

Question 1

Causes

Answer 1

Local
-Sinusitis 
-Trauma (picking, trauma to face) 
-Foreign body
-Neoplasm 
-Smoking 
-Blood thinners
-Illicit drugs 
-Septal deviation 
-Vascular malformation 
Systemic 
-Hemophilia 
-Leukemia 
-Liver Disease 
-Platelet dysfunction 
-Thrombocytopenic 
-OSA/CPAP
-COPD/Home O2
Environmental
-Humidity
-Allergens
-Home O2

Question 2

Investigations

Answer 2

CBC (HBG, platlets) 
Group and Screen 
Ferritin
INR/PTT
Creat 
ALP, ALT if recurrent

Question 3

Red Flags

Answer 3

Hemodynamic Instabiilty 
-Chest pain 
-SOB 
-Dizziness on standing 
Previous surgeries or septal deviation

Question 4

Physical Exam finding for anterior vs. Posterior Epistaxis

Answer 4

Blood in the oropharynx
Blood out of both nostrils during
Nausea/hematemesis
Melena

Question 5

Most likely location of the bleed originating from

Answer 5

Kesselbach’s Plexus

Question 6

What measurements would you want

Answer 6

Orthostatic BP

HR

Question 7

What other body parts would you want to examine

Answer 7

Skin (jaundice, spider nevi)
Hands (Duptrenes, palmar erythema)
Eyes (scleral icterus)
Cardiac (pulse and heart rate)

Question 8

Initial management

Answer 8

ABCs
Blow nose
2 sprays of oxymetazoline
Pressure against the septum 15 min in sniffing position

Cocaine/Lido with epi/TXA** soaked gauze
Cauterize
Merocel Tampon
Rhino rocket

** TXA is best especially if on antiplatlet agent
Reduces bleed risk at 1 week

Consider labs

Question 9

Chronic/long term management/education

Answer 9

Safety-Recurrent bleeding, signs of hemodynamic instability
Next steps-Referral to ENT
Offer follow up
Prevention-Don’t strain, sneeze with mouth open, no NSAIDS, moisturize air, avoid trauma,
Quit-Smoking, picking nose, drinking
Referral-ENT if recurrent
Start medication -Consider stopping blood thinners
Teach-Don’t strain, sneeze with mouth open, no NSAIDS, moisturize air, avoid trauma, review when to follow up, signs of hemodynamic instability, complications of treatments

Question 10

Anterior vs posterior sites and division line

Answer 10

Divides at the piriform aperature

Anterior comes from Kiesselbachs/littles and posterior comes from sphenopalatine
Majority come from the septrum