3.08 Epistaxis (Nosebleed)
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agk's Library of Common Simple Emergencies

Presentation
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A patient generally arrives in the emergency 
department with active bleeding from his nose 
or spitting up blood that is draining into his 
throat. There may or may not be a report of 
minor trauma such as sneezing, nose blowing or 
nasal manipulation. On occasion the hemorrhage 
has stopped but the patient is concerned 
because the bleeding has been recurring over 
the past few hours or days. Bleeding is most 
commonly visualized on the anterior aspect of 
the nasal septum within Kiesselbach's plexus. 
The anterior end of the inferior turbinate is 
another site where bleeding can be seen. Often, 
especially with posterior hemorrhaging, a 
specific bleeding site cannot be discerned.

What to do:
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- If significant blood loss is suspected, gain 
   vascular access and administer crystalloid 
   intravenous solution.
- Have the patient maintain compression on the 
   nostrils by pinching with a gauze sponge 
   while you assemble all equipment and 
   supplies at the bedside. Inform the patient 
   that you will be controlling the bleeding in 
   a stepwise fashion.
- Have the patient sit upright (unless hypo- 
   tensive) Sedate the patient if necessary 
   with a mild tranquilizer such as hydroxyzine 
   (Vistaril) or midazolam (Versed). Cover the 
   patient and yourself to protect your 
   clothes. Wear gloves.
- Prepare 5 ml of 4% cocaine solution or a 1:1 
   mixture of tetracaine 2% (Pontocaine) for 
   local anesthesia and epinephrine 1:1000 or 
   pseudophedrine 1% (Neo-Synephrine) for 
   vasoconstriction.
- Form two elongated cotton pledgets and soak 
   them in the solution.
- Use a bright headlight or head mirror to free 
   up hour hands and help insure good visualiz- 
   ation.
- Have the patient blow the clots from his nose 
   and quickly inspect for a bleeding site 
   using a nasal speculum and Frazier suction 
   tip. Clear out any additional clots or 
   foreign bodies.
- Insert the medicated cotton pledgets as far 
   back as possible into both nostrils.
- Have the patient relax with the pledgets in 
   place for approximately 5-10 minutes. You 
   may use this lull to ask the patient about 
   any past history of nosebleeds or other 
   bleeding problems, the pattern of this 
   nosebleed, which side the bleeding seems to 
   be coming from, any aspirin or blood 
   thinning medication, and any significant 
   medical or surgical problems.
- In the vast majority of cases, active 
   bleeding will stop with this treatment. The 
   cotton pledgets can be removed and the nasal 
   cavity can be inspected using a nasal 
   speculum and head lamp. If bleeding 
   continues, insert another pair of medicated 
   cotton pledgets.
- If the bleeding point can be located, 
   cauterize a l cm area of mucosa around the 
   bleeding site with a silver nitrate stick 
   and then cauterize the site itself. Observe 
   the patient for 15 minutes. If this stops 
   the bleeding, cover the cauterized area with 
   antibiotic ointment and instruct the patient 
   in prevention (avoid picking the nose, 
   bending over, sneezing, and straining) and 
   treatment of recurrences (compress below the 
   bridge of the nose with thumb and finger for 
   five minutes).
- If the bleeding point cannot be located or if 
   bleeding continues after cauterization, 
   insert an anterior pack. The best is a 1 cm 
   by 10 cm stick of compressed cellulose which 
   expands to conform (Merocel, Rhino Rocket). 
   To prevent putrification of the pack, partly 
   cover it with antibiotic ointment before 
   insertion. Leave some cellulose exposed to 
   allow for water absorption. Instill a few 
   drops of saline if it does not expand 
   spontaneously.
- An alternative anterior pack can be made from 
   up to six feet of half-inch ribbon gauze 
   impregnated with petroleum jelly (Vaseline). 
   Cover the gauze with antibiotic ointment and 
   insert it with bayonet forceps. Start with 
   3-4 plies layered accordion fashion on the 
   floor of the nasal cavity, placing it as far 
   posteriorly as possible, and pressing it 
   down firmly with each subsequent layer. 
   Continue inserting the gauze until the 
   affected nasal cavity is tightly filled 
   (expect to use about 3 to 5 feet per 
   nostril). If unilateral anterior nasal 
   packing does not provide enough pressure, 
   packing the opposite side of the nose 
   anteriorly can sometimes increase the 
   pressure by preventing the septum from 
   bowing over into the side of the nose that 
   is not packed.
- Observe the patient for 15 minutes. If no 
   further bleeding occurs in the nares or the 
   posterior oropharynx, discharge him on a 
   broad spectrum antibiotic (amoxicillin tid 
   250mg) for five days to help prevent a 
   secondary sinusitis. The packing should be 
   removed in 2-4 days.
- Tape a small folded gauze pad beneath the 
   nose to catch any minor drainage. The 
   patient can replace this from time to time 
   if necessary.
- Instruct the patient against sneezing with 
   his mouth closed, bending over, straining, 
   or nose picking. The patient's head should 
   be kept elevated for 24-48 hours. Provide 
   detailed printed instructions on home care.
- If the hemorrhage is suspected to have been 
   severe, obtain orthostatic blood pressure 
   and pulse recordings along with an 
   hematocrit before making a disposition for 
   the patient.
- If the hemorrhage does not stop after 
   adequate packing anteriorly, then one or two 
   posterior packs or nasal balloons should be 
   inserted, and the patient should be admitted 
   to the hospital under the care of an 
   otolaryngologist.

What not to do:
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- Do not waste time trying to locate a bleeding 
   site while brisk bleeding obscures your 
   vision in spite of vigorous suctioning. Have 
   the patient blow out any clots and insert 
   the medicated cotton pledgets.
- Do not get routine clotting studies unless 
   there is other evidence of an underlying 
   bleeding disorder.
- Do not cauterize or use instruments within 
   the nose before providing adequate topical 
   anesthesia (some initial blind suctioning 
   may, however, be required to clear the nose 
   of clots before instilling anesthetics).
- Do not discharge a patient as soon as the 
   bleeding stops, but keep him in the ED for 
   15-30 minutes more. Look behind the uvula. 
   If it is dripping blood, the bleeding has 
   not been controlled adequately. Posterior 
   epistaxis typically stops and starts 
   cyclically and may not be recognized until 
   all the above treatments have failed.

Discussion
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Nosebleeds are more common in winter, no doubt 
reflecting the low ambient humidity indoors and 
outdoors and the increased incidence of upper 
respiratory tract infections. Troublesome 
nosebleeds are more common in middle-aged and 
elderly patients. Causes are numerous: dry 
nasal mucosa, nose picking and vascular 
fragility are the most common, but others 
include foreign bodies, blood dyscrasias, nasal 
or sinus neoplasm or infection, septal deform- 
ity, atrophic rhinitis, hereditary hemorrhagic 
telaniectasis and angiofibroma. High blood 
pressure makes epistaxis difficult to control 
but is rarely the sole precipitating cause.

Drying and crusting of the bleeding site, along 
with nose picking, may result in recurrent 
nasal hemorrhage. It may be helpful to instruct 
the patient on gently inserting Vaseline onto 
his nasal septum once or twice a day to prevent 
future drying and bleeding. Other useful 
techniques include electrocautery down a metal 
suction catheter, ophthalmic electrocautery 
tips (see subungual hematoma), submucosal 
injection of lidocaine with epinephrine, and 
application of hemostatic collagen (Gelfoam). 
There are also several balloon devices to 
provide anterior and posterior tamponade, some 
with a channel to maintain a patent nares. 
Because of the nasopulmonary reflex, arterial 
oxygen pressure will drop about 15mmHg after 
the nose is packed, which can be troublesome in 
a patient with heart or lung disease, and 
usually requires hospitalization and 
supplemental oxygen.

References
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- Viducich RA, Blanda MP, Gerson LW: Posterior 
   epistaxis: clinical features and acute 
   complications. *Ann Emerg Med* 1995; 
   25:592-596.

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