CHAPTER

Epistaxis
(Nosebleed)
27
Presentation
The patient generally arrives in the ED or urgent care center with active bleeding from his
nose, or he may be 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 nose picking (epistaxis
digitorum). 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
present on the anterior aspect of the nasal septum within Kiesselbach’s area. 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 determined.

What To Do:
✓ If significant blood loss is suspected, gain vascular access and administer crystalloid IV
solution. Provide continuous cardiac monitoring and pulse oximetry. Controlling significant
hemorrhage should always take precedence over obtaining a detailed history or visualization
of a specific bleeding site.

✓ With all nosebleeds, have the patient maintain compression on the nostrils by pinching
with a gauze sponge while all equipment and supplies are being assembled at the bedside.
Inform the patient that the bleeding will be controlled in a stepwise fashion.

✓ Use of a headlight with a focused beam will allow you to have both hands free for
examination and manipulation while illuminating the nasal cavities and ensuring good
visualization.

✓ Have the patient sit upright (unless he is hypotensive). If necessary, sedate the patient
with a mild tranquilizer, such as hydroxyzine (Vistaril), 50 mg IM; lorazepam (Ativan), 1 mg SL,
IM, or IV; or midazolam (Versed), 0.5 mg IM or IV. Cover the patient and yourself to protect
clothing. Follow universal precautions by using gloves and wearing protective eyewear and a
surgical mask.

✓ Prepare 5 mL of 4% cocaine solution or a 1:1 mixture of tetracaine 2% (Pontocaine)

or lidocaine 4% (Xylocaine) for topical anesthesia, along with epinephrine 1:1000 or
pseudoephedrine 1% (Neo-Synephrine) for topical vasoconstriction.

✓ Form two elongated cotton pledgets (each approximately ¼ the volume of a cotton
ball) and soak them in this solution.

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Figure 27-2 Insertion of medicated cotton pledgets.

Figure 27-1 The patient must blow the clots from his nose
prior to the insertion of medicated cotton pledgets.

✓ Instruct the patient to blow the clots from his nose, and then quickly inspect for a
bleeding site using a nasal speculum and Frazier suction tip. Clear out any additional
clots or foreign bodies (Figure 27-1). The bleeding may be too brisk to identify a bleeding
site at this time, and, therefore, inspection may be delayed until vasoconstriction has slowed
the hemorrhage.

✓ Insert the medicated cotton pledgets as far back as possible into both nostrils
using bayonet forceps (Figure 27-2).

✓ Allow the patient to relax with the pledgets in place for approximately 5 to 20 minutes.
Having the patient pinch the anterior half of his nose, compressing the nasal septum, will
help stop any further bleeding.

✓ During this lull, inquire about the patient’s history of nosebleeds or other bleeding
problems, the pattern of this nosebleed, which side the bleeding seems to be coming from,
use of any aspirin or blood-thinning medication, and any significant medical or surgical
problems. Often, no cause for the bleeding can be identified, but when there is diffuse
oozing, multiple bleeding sites, or recurrent bleeding, or if the patient is taking an
anticoagulant, a hematologic evaluation should be performed. CBC, INR, PT, PTT, platelet
count, and, if significant blood loss is suspected, blood typing and crossmatching should all
be obtained.

✓ In most cases, active bleeding will stop with use of vasoconstrictors alone. The
cotton pledgets can be removed, and the nasal cavity can be inspected using a nasal
speculum and head lamp. Gently inserting a nasal speculum and spreading the naris
vertically will permit visualization of most anterior bleeding sources. If bleeding continues,
insert another pair of medicated cotton pledgets and repeat this procedure with more
prolonged nasal compression. (Commercially available nasal clips can accomplish this for your
patient.)

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Figure 27-3 Cauterize mucosa with a silver nitrate stick.

✓ Although infrequent, there are times when the patient is hemorrhaging so briskly
that the nose must be tamponaded using a balloon catheter or gauze pack (see below)
without inspection, topical anesthesia, or attempted cautery.

✓ If the bleeding point can be located and the bleeding is not too brisk, attempt to
cauterize a 0.5-cm area of mucosa around the bleeding site with a silver nitrate stick,
and then cauterize the site itself. If there is an individual vessel bleeding rapidly, hold the
tip of the cautery stick on top of that vessel with pressure, for up to 20 seconds, until the
bleeding stops (Figure 27-3).

✓ Observe the patient for 15 minutes. If this cauterization stops the bleeding, either
cover the site with absorbable gelatin foam (Gelfoam) or oxidized cellulose (Surgicel) or just
cover the cauterized area with an antibiotic ointment (Bacitracin).

✓ Instruct the patient about 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 5 to 10 minutes). To help prevent recurrent bleeding, instruct the patient
to apply skin moisturizer or petroleum jelly onto the nasal septum once or twice a day during
dry weather to keep the mucosa from drying and bleeding.

✓ If the bleeding point cannot be located or if bleeding continues after cauterization,

insert an anterior pack. The easiest of the commercially available nasal tampons to
insert, and possibly the most comfortable for the patient, is the gel-coated, balloon-
inflated Rapid Rhino nasal pack. Soak the knit fabric-covered balloon in water until the
fabric is completely converted into a gel. Insert the entire length of this balloon posteriorly
along the floor of the nasal cavity. Inflate the balloon with 10 to 15 mL of air or until the
pilot cuff feels firm.

✓ An alternative is to use an 8-cm stick of compressed cellulose (Merocel, Rhino Rocket)

that expands to conform to the inside of the nasal cavity. A shorter pack may be used for

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Figure 27-4 Packing the nasal cavity with ribbon gauze.

purely anterior bleeding, or two Merocel packs can be inserted at the same time to provide a
thicker tampon. To prevent putrefaction of the pack and provide some lubrication, partly
cover it with antibiotic ointment before insertion. Leave some cellulose exposed to allow
water absorption. Quickly and firmly push the tampon posteriorly and straight back along the
floor of the nasal cavity until it goes no further. This may cause discomfort, but if you hesitate
during the insertion, the tampon will begin to expand and soften, and you will not be able to
push it completely into place. Instill several milliliters of saline, or the topical vasoconstrictor, if
the compressed cellulose does not expand spontaneously. Tape the free end of the suture
that is attached to the tampon to the patient’s cheek or nose. This will help later with its
removal.

✓ An alternative anterior pack can be made from up to 6 feet of 1/2-inch ribbon gauze
impregnated with petroleum jelly (Vaseline). Cover the gauze with antibiotic ointment
(e.g., Bacitracin), and insert it with bayonet forceps. Start with three to four layers placed in
accordion fashion on the floor of the nasal cavity, placing the gauze as far posteriorly as
possible (leaving the free ends protruding anteriorly) 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 (Figure 27-4). Nonadherent gauze impregnated with petroleum jelly and 3%
bismuth tribromophenate (Xeroform) also can work for such an anterior pack.

✓ Other useful techniques for providing hemostasis include electrocautery down a metal
suction catheter, ophthalmic electrocautery tips, or submucosal injection of lidocaine with
epinephrine.

✓ In patients with a bleeding disorder, application of fibrin sealant spray (Crosseal) or

thrombin combined with gelatin foam (FloSeal) can be used. Topical thrombin spray or

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powder (Thrombin-JMI) is another option for use with complex bleeding problems, but
all of these products are very expensive.

✓ Observe the patient for 15 to 30 minutes. If there is no further bleeding observed

in the nares or the posterior oropharynx, the patient may be discharged.

✓ If a nasal pack or balloon was inserted, the patient should be sent home on a
regimen of antibiotics (cephalexin [Keflex], 500 mg qid; amoxicillin/clavulanate
[Augmentin], 875/125 mg bid; or, if penicillin allergic, clindamycin [Cleocin], 300 mg qid
or trimethoprim/sulfamethoxazole [Bactrim, Septra] DS bid) for 4 to 5 days to help
prevent a secondary sinusitis and reduce the risk for toxic shock syndrome.

✓ The packing should be removed in 3 to 4 days.

✓ If pain is a problem, prescribe hydrocodone bitartrate with acetaminophen (Vicodin ES) if

acetaminophen (Tylenol) alone is inadequate. Avoid NSAIDs and aspirin.

✓ 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.

✓ Always inspect the posterior nasopharynx prior to discharging the patient, looking
for any continued occult hemorrhage.

✓ Warn the patient about not sneezing with his mouth closed, bending over, straining, and/
or picking his nose. The patient should keep his head elevated for 24 to 48 hours. Provide
detailed printed instructions regarding home care.

✓ Follow-up, preferably by an ear, nose, and throat (ENT) specialist, should be provided
within the next 48 to 72 hours.

✓ If the hemorrhage is suspected to have been severe, determine the patient’s

orthostatic blood pressure, pulse, and hematocrit level before sending him home.

✓ Elderly patients or patients with cardiac disorders or chronic obstructive

pulmonary disease should be considered for hospitalization, even if they only have an
anterior pack, if they are having any problems with oxygen saturation.

✓ If the hemorrhage does not stop after adequate packing anteriorly, unilateral or bilateral
posterior packs or nasal balloons should be inserted, and the patient should be admitted to a
monitored hospital bed under the care of an otolaryngologist. A lubricated double-balloon
device (EpiStat, Nasostat) (Figure 27-5) is passed into the affected nostril until it reaches the
posterior nasopharynx. The posterior balloon is then inflated with the manufacturer’s
recommended volume of normal saline, and the anterior portion of the device is withdrawn
so that the posterior balloon seats snugly in the posterior nasal cavity to tamponade any
bleeding. The anterior balloon is then inflated with the recommended volume of saline
to prevent the posterior balloon from becoming unseated and possibly obstructing the
airway.

✓ If a patient returns with mild oozing of blood from around an anterior pack, you
may be able to stop the bleeding by using a needle and syringe to inject the packing
(not the patient) with the vasoconstricting solution described earlier. (If the Rapid
Rhino was used, recurrent oozing can often be stopped by just reinflating its balloon
with air.)

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A Figure 27-5 Double balloon devices. A, Epistat (Medtronic

Xomed, Jacksonville, Fla) and B, Nasostat (Sparta,
Pleasanton, Calif).

✓ When removing a compressed cellulose pack on a follow-up visit, soften it with 1 to

2 mL of water and wait 5 minutes, thereby reducing trauma, pain, and the incidence of
rebleeding.

What Not To Do:

✗ Do not waste time trying to locate a bleeding site if brisk bleeding is obscuring your
vision in spite of vigorous suctioning. Have the patient blow out any clots, and insert the
medicated cotton pledgets immediately or go directly to anterior packing.

✗ Do not order routine clotting studies unless there is persistent or recurrent bleeding, use
of anticoagulant medications, or other evidence of an underlying bleeding disorder identified
on the history or medical examination.

✗ Do not cauterize or place a painful device in the nose before providing adequate topical
anesthesia unless rapid hemorrhaging requires it.

✗ Do not cauterize corresponding areas on both sides of the nasal septum because this
may increase the risk for development of a septal perforation.

✗ Do not use an inadequate amount of gauze packing. It will only serve as a plug in the
anterior nares rather than as a hemostatic pack.

✗ Do not discharge a patient as soon as the bleeding stops, but keep him in the ED for 15
to 30 minutes more. Look behind the uvula. If there is active blood flow, the bleeding has not
been controlled adequately. Posterior epistaxis typically stops and starts cyclically and may
not be recognized until all of the aforementioned treatments have failed.

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Discussion
Epistaxis (Greek for nosebleed) affects people in
all age groups but is most common and more
troublesome in the elderly. Children tend to
bleed secondary to nose picking; adolescents
bleed secondary to facial trauma associated with
athletic activity or fighting. Epistaxis in the
middle-age patient is more often the harbinger
of neoplastic disease. Nosebleeds in the elderly
are generally the result of underlying vascular
fragility in combination with blood-thinning
medications.
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.
In most cases, anterior bleeding is clinically
obvious. In contrast, posterior bleeding may be
asymptomatic or may present insidiously as
nausea, hematemesis, anemia, hemoptysis, or
melena.
Causes of epistaxis are numerous; dry nasal
mucosa, nose picking, and vascular fragility are
the most common causes, but others include
trauma, foreign bodies, blood dyscrasias, nasal
or sinus neoplasm or infection, septal deformity
or perforation, atrophic rhinitis, hereditary
hemorrhagic telangiectasis, and angiofibroma.
Epistaxis that results from minor blunt trauma
in healthy individuals rarely requires any
intervention and will spontaneously subside
with head elevation alone and avoidance of any
nasal manipulation. (Always inspect for a
possible septal hematoma.)
High blood pressure may make epistaxis more
difficult to control; however, although it is often
present with epistaxis, it is rarely the sole
precipitating cause. Specific antihypertensive
therapy is rarely required and should be avoided
in the setting of significant hemorrhage.
Use of medications, especially aspirin, NSAIDs,
warfarin (Coumadin), heparin, enoxaparin
(Lovenox), ticlopidine (Ticlid), dipyridamole
(Persantine), and clopidogrel (Plavix), not only
predisposes patients to epistaxis but also makes
treatment more difficult.
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Hereditary hemorrhagic telangiectasia is the
most common systemic disorder of the vascular
system that affects the nasal mucosa. Onset of
symptoms is usually at puberty and
progressively worsens with age.
Blood dyscrasias can be found in patients
with lymphoproliferative disorders,
immunodeficiency, or systemic disease or in
the alcoholic patient. Thrombocytopenia can
lead to spontaneous mucous-membrane
bleeding with platelet counts of 10,000/mm3
to 20,000/mm3.
Platelet deficiency can be the result of
chemotherapy agents, malignancies,
hypersplenism, disseminated intravascular
coagulopathy (DIC), drugs, and many other
disorders. Platelet dysfunction can be seen in
liver failure, kidney failure, and vitamin C
deficiency as well as in patients taking aspirin
and NSAIDs.
Von Willebrand disease is the most common
clotting factor abnormality that can result in
frequent, recurring nosebleeds. Factor VIII
deficiency (hemophilia A) and factor IX
deficiency (hemophilia B) are also common
primary coagulopathies.
One study of chronic nosebleeds in children
showed that a third of these patients can be
expected to have a coagulation disorder. The
single best predictor of coagulopathy is family
history.
Because of the nasopulmonary reflex, arterial
oxygen pressure will drop about 15 mm Hg after
the nose is packed, which can be troublesome in
a patient with heart or lung disease and often
requires hospitalization and supplemental
oxygen.
Tumors or other serious diseases are infrequent
causes of epistaxis. However, it is prudent for all
patients who present with nosebleeds to have a
complete nasopharyngeal examination by an
ENT specialist in follow-up.
 EPISTAXIS NOSEBLEED

Suggested Readings
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arterial hypertension. Am J Emerg Med 20:92-95, 2002.

Herkner H, Laggner A, Müllner M, et al: Hypertension in patients presenting with epistaxis.

Ann Emerg Med 35:126-130, 2000.

Kucik CJ, Clenney T: Management of epistaxis. Am Fam Physician 71:305-311, 2005.

Pringle MB, Beasley P, Brightwell AP: The use of Merocel nasal packs in the treatment of
epistaxis. J Laryngol Otol 110:543-546, 1996.

Sandoval C, Dong S, Visintainer P, et al: Clinical and laboratory features of 178 children with
recurrent epistaxis. J Pediatr Hematol Oncol 24:47-49, 2002.

Singer AJ, Blanda M, Cronin K, et al: Comparison of nasal tampons for the treatment of
epistaxis in the emergency department: a randomized controlled trial. Ann Emerg Med 45:134-
139, 2005.

Thaha MA: Routine coagulation screening in the management of emergency admission for
epistaxis: is it necessary? J Laryngol Otol 114:38-40, 2000.

Vaiman M, Martinovich U, Eviatar E: Fibrin glue in initial treatment of epistaxis in hereditary

haemorrhagic telangiectasis. Blood Coagul Fibrinolysis 15:359-363, 2004.

Vaiman M, Segal S, Eviatar E: Fibrin glue: treatment for epistaxis. Rhinology 40:88-91, 2002.

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