Epistaxis (nosebleed) Flashcards
What part of the nose is most commonly known to bleed?
The most common bleed is from the anterior part of the septum, which accounts for 90% of the nose bleeds.
The anterior region of the Kiesselbach plexus is formed from the internal carotid artery, which produces an ophthalmic artery, which then terminate to the ethmoid and septal arteries. Specifically, the Kiesselbach plexus is the anastomosis of the septal branch of the anterior ethmoidal artery and the lateral nasal branch of the sphenopalatine artery. Another vessel from the facial artery joins the network from the superior septal branch.
What labs are indicated for nosebleeds?
A targeted history can help to rule out other conditions that predispose to bleeding, but in general the labs that are indicated are, Coags (for anticoagulated patients), CBC, type-screen or cross-match.
What is a common cause for epistaxis in an adult?
Cocaine abuse is a possible etiology in any patient and must be considered. A perforated nasal septum can be a warning sign.
Other causes are trauma, Afrin, or prior surgery.
Recurrent bleeding from the back of the nose in an adolescent male is considered to be _______ until proven otherwise.
Juvenile nasopharyngeal angiofibroma
These patients frequently also have nasal obstruction.
Diagnosis is made by physical examination with nasal endoscopy.
Patients with hypertension and arthritis (for which they are taking aspirin), who have frequent nosebleeds, are treated with … ?
Topical vasoconstriction (oxymetazoline, phenylephrine), which almost always stops the bleeding. These patients should also be treated with medication to lower their blood pressure. The diastolic pressure has to be reduced below 90 mm Hg.
What is the approach to nose bleeding if the nosebleed is anterior and the source can be seen?
If anterior and a bleeding source is seen, it can be cauterized with either electric cautery or chemical cauterization with silver nitrate and packing (nasal tampons, ribbon gauze, nasal balloon catheter).
Nasal endoscopes permit identification of the bleeding site, even if it is not immediately seen on the anterior septum.
What is the measure performed for epistaxis when the bleeding will not stop and can not be seen?
When posterior nosebleeds can not be stopped, treatments include:
- Packing (nasal tampons, ribbon gauze, nasal balloon catheter)
- Balloon catheter is preferred or a Foley catheter can be used
These patients may require hospitalization and ENT consultation.
Once a patient presents with a nosebleed and is properly managed, when can a patient be discharged home?
When would they needed to be admitted for observation?
Patients who undergo anterior packing on one side may go home.
Many patients can then go home, using oxymetazoline for a few days. Furthermore, methylcellulose coated with antibiotic ointment can be placed into the nose to prevent further trauma and allow the mucosal surfaces to heal. This is usually left in place for 3 to 5 days.
Bilateral nasal packing is used or if a posterior pack is placed, patients will need to be admitted to the hospital and carefully watched, because they can suffer from hyperventilation and oxygen desaturation.
In general, the packing is left in place for three to five days and removed. During this time, prophylactic oral or parenteral antibiotics should be administered to decrease risk of infectious complications.
If the patient re-bleeds, the packing should be replaced, and arterial ligation, endoscopic cautery, or embolization can be considered. As always, these patients should be worked up for bleeding disorders.
A patient with a severe nosebleed can develop
Hypovolemia, or significant anemia, if fluid is being replaced.
These conditions necessitate increased cardiac output, which can lead to ischemia or infarction of the heart itself.
Posterior epistaxis occurs from which branches?
This is less common (10% of the nose bleeds) and may result in significant hemorrhage. The posterior bleeding occurs from the posterolateral branches of the sphenopalatine artery, which is the terminal branch of the maxillary artery (which comes from the external carotid). Rarely the external carotid artery can cause this hemorrhage.
What are the causes for epistaxis?
Local causes of epistaxis include mucosal irritation (eg, nose picking, dry air, rhinitis, foreign body), facial trauma, intranasal drugs (cocaine, intranasal corticosteroids), or tumors (nasopharyngeal carcinomas). Systemic conditions or drugs may also cause epistaxis (eg, anticoagulation, antiplatelet medications, alcohol, bleeding disorders [eg, von Willebrand disease], vascular malformations [nasal hemangioma], or hypertension).
The most common initiating event for these kinds of nosebleeds is digital trauma from a fingernail. Children’s fingernails should be trimmed, and adults should be informed about avoiding digital trauma. Another consideration may be an occult bleeding disorder; therefore, adequate coagulation parameters should be studied if the patient continues to have problems.
What are the initial steps in management for epistaxis (either anterior or posterior)?
ABC’s: Assess and treat for airway, breathing, and circulation
(fluid resuscitation, redundant large-bore IV lines as indicated).
Position the head forward.
Provide oxymetazoline or phenylephrine nasal spray (and possibly lidocaine) and digital pressure for 5–10 minutes.
Cold compress.
What are the major complications of epistaxis?
Prolonged retention of nasal packing (>72 hours) increases the risk of complications, including necrosis, toxic shock syndrome, sinus or nasolacrimal infections, and dislodgement.
A patient subsequently presents with fever, hypotension, desquamation, and mucosal hyperemia after receiving nasal packing, what is the likely issue?
toxic shock syndrome
Brisk bleeding even after adequate nasal packing may indicate
a posterior source of bleeding
