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Epistaxis is defined as acute hemorrhage from thenostril, nasal cavity, or nasopharynx. Nosebleedsare a common condition and most are self-

limiting. However, uncontrolled nasal bleeding can leadto hypovolemia and airway compromise. This articlereviews the risk factors, prevention, and managementof epistaxis, including management for patients onanticoagulants or supplemental oxygen. Newer treat-ment options offer patients and clinicians a betterarsenal to treat epistaxis.

CAUSES

Epistaxis is a frequent phenomenon. An estimated 60%

of the population will have a nosebleed in their lifetime,and 6% require medical intervention.1,2The incidence ofepistaxis is a bimodal distribution, peaking in youngchildren and again in adults ages 45 to 65 years.2Epistaxis

can be caused by a variety of factors (Table 1). Antico-agulation, underlying liver disorders, or other bloodcoagulopathies can contribute to the inability to controlepistaxis. Recurrent or unilateral epistaxis along withnasal congestion or nasal obstruction, independent of thedegree of bleeding, may indicate nasal neoplasm.

Linda Diamond practices ENT head and neck surgery at Allegheny

General Hospital in Pittsburgh, Pa. The author has disclosed no

potential conflicts of interest, financial or otherwise.

DOI: 10.1097/01.JAA.0000455643.58683.26

Copyright 2014 American Academy of Physician Assistants

Managing epistaxisLinda Diamond, PA-C

ABSTRACT

An estimated 60% of the population will have a nosebleedin their lifetime, and 6% will require medical interven-tion. Uncontrolled nasal bleeding can lead to hypovolemiaand airway compromise. Understanding prevention andmanagement of epistaxis is especially important to clini-cians who manage patients on anticoagulants, supplementaloxygen therapy, or who have other risk factors for epistaxis.This article reviews stepwise management for epistaxis and

newer treatment options in adults.Keywords:epistaxis, nosebleeds, nasal packing, thrombo-genic agents, balloon catheter, anticoagulation

Learning objectives

Identify risk factors and causes of epistaxis.Describe the stepwise management of epistaxis.List the equipment and medications needed tomanage epistaxis.

FIGURE 1.Anatomy of the nasal cavity

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ANATOMY

The nasal cavitytwo chambers divided by the nasalseptumwarms and moistens the air we breathe. Theseptum is lined by mucous membrane and contains arich vascular supply generating from branches of theinternal and external carotid arteries. More than 90%of cases of epistaxis occur on the nasal septum in thevascular area called the Kiesselbach plexus.1This areais prone to digital trauma and excessive drying, and isexacerbated by the use of supplemental oxygen via nasalcannula. The Kiesselbach plexus is supplied by both theanterior and posterior ethmoid arteries as well asbranches from the sphenopalatine and greater palatinearteries (Figure 1). Epistaxis in this area is definedas anterior and is generally self-limiting and easier tocontrol.

The lateral wall of the nasal cavity is more complex, withthree bony elevations called turbinates or conchae. Theseconchae are covered with a thick mucous membrane andincrease the surface area to moisten inhaled air. Posteriornasal cavity epistaxis occurs in 5% to 10% of nasal bleed-ing.1Branches of the internal maxillary artery (spheno-palatine and descending palatine arteries) with a smallcontribution from the posterior ethmoid artery make upthe vascular supply to this area. Posterior epistaxis is oftenmore difficult to visualize and to reach anatomically,therefore, more difficult to control.1,2

HISTORY AND ASSESSMENT

Obtaining a timeline of the patients nosebleed is important;

the duration of the bleeding may indicate whether thepatient needs more emergent treatment. Refer the patientto the nearest ED if he or she has had recurrent hard-to-control bleeding over several days or a single significantbleed lasting longer than 1 hour.

Review the patients medical history, looking forchronic medical conditions that may predispose thepatient to bleeding, such as hypertension, liver disease,heart disease, or blood disorders. Note and documentif the patient is taking anticoagulants or antiplatelet

drugs such as aspirin and nonsteroidal anti-inflammatorydrugs (NSAIDs).

In the initial evaluation of a patient with epistaxis, focuson airway competency and cardiovascular stability. Patientswith severe bleeding may need resuscitation and airwaycontrol. Be sure to have adequate lighting when inspectingthe nasal cavity in the office setting. A headlight source witha nasal speculum is recommended. Inexpensive headlampsused for camping or recreation can provide a narrow tightbeam, allowing better visualization and freeing both of thehealthcare providers hands. The patient should be sittingupright on examination chair or table to limit head movement.

An epistaxis kit containing all the necessary instrumentsand packing is helpful (Table 2). Bayonet forceps or straight

sturdy blunt-ended tweezers about 8 in long are used to insertpledgets or packing. Frasier suction #10 or small disposablesuction tips are used to remove clots and blood from thenasal cavity before treatment. Yankauer suction and anemesis basin can be used to capture expectorated clots.

TREATING ANTERIOR EPISTAXIS

Epistaxis treatment is based on the site and degree ofbleeding. Failure to control an anterior bleed may indicatethe presence of a posterior bleed.

Key points

An estimated 60% of the population will have epistaxis at

some time, and 6% will require medical treatment.

Newer options for nasal packing and thrombogenic

materials are less traumatic for patients and healthcare

professionals.

Patients on anticoagulant or antiplatelet medications

should be instructed in nasal care to reduce the risk of

epistaxis.

An epistaxis kit of necessary instruments and supplies may

help healthcare providers treat patients more efficiently

and effectively.

Traumatic

Nose picking

Facial injury

Foreign body

Nasogastric tube placements

Barotrauma

Neoplastic

Benign

Malignant

Hematologic

Thrombocytopenia

Hemophilia

Von Willebrand disease

Hereditary hemorrhagic telangiectasia

Hepatic diseases

Anticoagulant or antiplatelet medications

Structural Dryness

Septal perforation

Surgical procedures

Drug-induced

Nasal sprays

Substance inhalation

Inflammatory

Environmental irritants

Allergic rhinitis

Infections

TABLE 1.Causes of epistaxis

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Compression is recommended initially for a simpleanterior septal nosebleed. Have the patient watch a clockor set a timer while holding the fleshy part of the nosefor 10 minutes without releasing. If this method fails, thepatient will require medical evaluation by a primary care

provider, ENT specialist, or in an urgent or emergencycare setting.Inspect for bleeding in the Kiesselbach plexus. A locally

applied vasoconstrictor can assist visualization and controlof bleeding. Oxymetazoline, the active ingredient in severalnasal decongestant sprays, is available and easy to use.Suction or have the patient gently blow the nose, theneither spray or place a cotton pledget soaked with oxy-metazoline in the nares. A pledget can be made using alarge cotton ball and unrolling it to about 4 in long. Thepledget is best placed using bayonet forceps to insure properplacement along the nasal septum. Let the pledget remainin place with gentle compression for 5 to 10 minutes. Afterremoving the pledget, examine the nares with a headlightand nasal speculum.

Chemical cautery may be considered for persistentoozing of an identifiable anterior site. Anesthetize thepatients nasal cavity with a pledget soaked with 2%lidocaine (with or without epinephrine) for about 10minutes. Remove the pledget and hold a silver nitrateapplicator on the site of bleeding and surrounding areafor no longer than 10 seconds. The mucosa will turnwhitish gray. Holding the cautery stick on an area formore than 10 seconds poses the risk of septal perforation.Use caution in cauterizing both sides of the septum in thesame session, as this may also cause tissue necrosis andpossible septal perforation.

Nasal packingis available for anterior and posteriorbleeding. For a simple anterior nasal bleed that has failedcompression and/or cautery, use a nasal tampon, balloon,or a thrombogenic agent. Occasionally, both sides of thenares may require packing either due to bilateral bleedingor to achieve enough compression to control the bleed.Bilateral packing is necessary for patients with septalperforation.

Nasal tamponsare made of a synthetic open-cell poly-mer. Although these polyvinyl alcohol sponges are rigid,they are easy to use and effective. Anesthetize the patientsnare as described above. Coat the nasal tampon withantibiotic ointment to act as a lubricant as well as to

prevent infection. Slide the nasal tampon directly alongthe floor of the nasal cavity until the entire tampon is inthe nasal cavity. Then expand the tampon by infusingabout 10 mL of saline or sterile water with an angiocath-eter or needle onto the anterior nasal tampon to soak thematerial.

Nasal balloon catheters come in different types, includ-ing a low-pressure balloon encased in a carboxymethylatedcellulose (CMC) mesh. The mesh promotes thrombosisonce it contacts blood. These balloon catheters are con-

sidered less traumatizing to the nose than traditional nasaltampons. They vary in length to allow compression fromthe anterior to more posterior bleeding sites. CMC bal-loons are moistened with sterile water before insertion,and are easy to insert in the nares in the office setting.Remove the hard outer cover, moisten the pack withsterile water, and immediately slide the pack along thefloor of the nose until it is completely inserted. (None ofthe pack should be sticking out of the patients nose.) Theninflate with air until the pilot cuff is firm. Tape the cuff tothe patients cheek.

Gauze packingwith petroleum-impregnated ribbon gauzecan be used to control epistaxis. The packing is placedwith a bayonet forcep. Grasp the gauze and place it as farback in the nasal cavity as possible, then grasp the nextsegment of gauze and tightly layer each segment into thenare. This requires a greater skill in placement and maybe deferred to an ENT specialist.

Thrombogenic agentsare newer options to promoteclot formation and stabilize epistaxis. Forms includesurgical absorbable gauze, topical thrombin gel, and fibrin

glue. The medicated gauze and topical applications con-form to irregular and wet mucosal surfaces. Medicatedgauze can be placed after cautery in patients at high riskfor recurrent bleeding. Studies indicate that thrombogenicagents have a lower rebleeding rate and effectively controlepistaxis.3,4Patients have less nasal pressure and find theseinterventions more comfortable than traditional nasalpacking or balloons. Because this form of treatment isabsorbable, it does not have to be removed. This preventsclots from being dislodged or the nasal mucosa from

Head lamp

Nasal speculum

Bayonet forceps

Frasier suction #10

Suction setup

Emesis basin

Oxymetazoline

Lidocaine 2% with or without epinephrine

Cotton pledgets or balls/strips

Tongue blades

Eye protection

Nonsterile gloves

Silver nitrate sticks

Antibiotic ointment

Empty 10-mL syringes

Sterile water

Anterior packing (polyvinyl alcohol sponge or low-

pressure balloon)

Posterior packing (dual balloon catheter or petroleum-impregnated gauze)

Hemostatic agents of choice

TABLE 2.Contents of an epistaxis kit

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being further irritated, as can occur during removal oftraditional packing.

Thrombogenic agents need to be applied directly to thearea of bleeding and compression may still be requiredinitially. When evaluating bleeding, remember that these

agents may take several minutes to work.

TREATING POSTERIOR EPISTAXIS

Because visualization and access to the bleeding site isdifficult, posterior epistaxis is challenging to treat. Thenares can be packed with petroleum-impregnated gauzeor a posterior balloon can be placed. A dual ballooncatheter is inserted along the floor of the nose until theretention ring is at the nasal entrance. The posterior bal-

loon is inflated with 10 mL of sterile water and the cath-eter is gently pulled forward until it lodges against thenasopharynx. The anterior balloon is then inflated withup to 30 mL of sterile water to hold the catheter in place.Pad or protect the nasal entrance from any pressure theballoon may create in its placement.

Although not licensed for this use, an indwelling urinarycatheter works well if a balloon catheter is not available.Insert a 10-to-14 French catheter into the nasal cavity untilthe indwelling urinary catheter is visible in the oropharynx.Then slowly inflate the balloon with 10 mL of sterile waterand gently withdraw the catheter until compression occurson the posterior nasopharynx. While maintaining pressureon the posterior nasopharynx (pulling the catheter towardyourself), place a small C-clamp or umbilical clamp at theanterior nares to hold the catheter. Ribbon gauze or pack-ing may be placed around the catheter inside the nares foradded compression and control of bleeding. Apply a gauzedressing to protect the external nares from the clamp andpressure necrosis.

AFTER PACKING TREATMENT

After the nasal cavity has been treated or packed, alwaysuse a light source and tongue blade to evaluate theoropharynx to check for posterior bleeding. Epistaxisthat persists after packing is placed requires immediatereferral to an ED. Packing that results in good controlshould remain in place for 3 to 5 days. Although expertshave debated whether to prescribe prophylactic oralantibiotics to prevent toxic shock syndrome and sinus-itis while the packing is in place, most ENT surgeons

prefer prophylaxis.5Simple anterior packing on one sidecan be treated as an outpatient procedure, with referral toan ENT specialist for follow-up in 3 to 5 days.

Patients who require bilateral packing or posteriorpacking will need hospital admission and monitoring.

The potential risk of hypotension and bradycardia causedby a nasovagal reflex is rare. This nasopulmonaryreflex was thought to occur during posterior nasalpacking or instrumentation but studies have demon-strated no change in pulmonary or cardiac function inrelation to posterior nasal packing.6Patients are at pos-sible risk of short-term sleep apnea due to the decreasednasal air entry from the packing.1,4The risk of displace-ment of the packing and possible recurrent bleedingwarrants ICU admission or a high level of monitoring.A hospitalized patient will benefit from a humidifiedface tent to provide moisture and comfort; the nasalpacking forces patients to breathe through the mouthwhile sleeping.

UNCONTROLLED EPISTAXIS

Angiography with embolizationwas first performed forepistaxis in 1972.2Since then, it has become a commonalternative for uncontrolled epistaxis in medical centerswhere it is available. Patients usually require anesthesiaand must tolerate IV contrast for this procedure.

Studying endovascular treatment for intractable epistaxisin 30 patients, Vitek found a success rate of 87% afterembolization of the internal maxillary artery and a 97%success rate after embolization of the internal and facialarteries, with a 3% to 4% complication rate.7Failure ofembolization treatment of epistaxis is often related tocontinued bleeding from the ethmoidal branches of theophthalmic artery. Embolization of these branches iscontraindicated because ophthalmic artery embolizationcarries a high risk of blindness and stroke.

Surgical treatment isreserved for ongoing hemorrhagethat fails conservative interventions. Surgery is performedin the OR under general anesthesia; rigid endoscopyis used to identify the site of bleeding. Surgical ligationor cautery of the sphenopalatine artery is attemptedinitially. Studies of posterior endoscopic cauterizationreport success rates of 80% to 90%.2If the site of bleed-ing is found from the ethmoidal region, a ligation of theethmoid artery is completed. This may require an exter-

nal incision through the medial orbital wall just belowthe eyebrow. Traditional or absorbable nasal packingmay be placed in the nasal cavity postprocedure as aprecaution.

ANTICOAGULATION AND HYPERTENSION

Managing epistaxis in patients taking anticoagulants ischallenging. Much debate and little consensus exist as towhether anticoagulation should be continued, held,or reversed when patients develop epistaxis.3Medically

Surgical treatment is reserved

for ongoing hemorrhage thatfails conservative interventions.

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evaluate each patient to determine the risks of stoppinganticoagulation.

The role of hypertension in the initial onset of epistaxisis controversial.8,9Studies have demonstrated that patientswith epistaxis presenting to the ED have higher BP on

admission than controls. These patients also have a higherincidence of previous nosebleeds.9Patients with epistaxisand uncontrolled BP can have persistent bleeding that isdifficult to control, so medical management of hyperten-sion is vital. The hypothesis that elevated BP was second-ary to anxiety during epistaxis also was studied. Thisprospective comparative study looked at administering

diazepam to patients with epistaxis, increased BP, andanxiety. The researchers found that diazepam did notreduce anxiety or BP during acute epistaxis and was notrecommended.10Therefore, evidence supports that hyper-tension itself must be controlled in a patient with acuteepistaxis and should be monitored closely.

FOLLOW-UP AND PREVENTION

All patients with a history of severe or recurrent epistaxisshould have an ENT evaluation. Provide patients withwritten instructions for nasal care after epistaxis: Patients should not blow their noses for 7 to 10 daysafter the nosebleed. Patients should use saline nasal sprayseveral times a day and sniff gently instead of blowingthe nose. Patients should apply petroleum or antibiotic ointmentin the nares twice a day. Patients should avoid bending and lifting heavy objects. Advise patients to open their mouths when sneezing. Patients should use home humidifiers and bedsidevaporizers.

Tell patients to keep fingernails trimmed and avoid nosepicking. For patients on supplemental oxygen, a humidified facetent or mask is recommended. Limit the use of a nasalcannula to during meals. Patients also should trim theprongs of the tubing that enter the nose to prevent exces-sive dryness on the septum.

Moisture is the key to prevention. All patients on anti-coagulation or antiplatelet medications (including NSAIDs)should use nasal care. Patients with nasal dryness or a

history of nosebleeds should add nasal care to their dailyregime.

Most nosebleeds are cyclic. A patient may have anidiopathic nosebleed that stops as a clot is formed overthe bleeding site. If the patients nose becomes dry or is

blown and the clot becomes dislodged too soon, the nosebleeds again. Until the mucosa underlying the clot isallowed to heal, a patient may continue to have serialbleeds. Moisture and prohibiting nose-blowing stops thiscycle and lets the nasal lining heal. Teaching patients howto correctly try to control a nosebleed and perform propernasal care after a nosebleed may prevent an unnecessarytrip to a clinic or ED.

CONCLUSION

Epistaxis is a common medical event. Newer treatmentoptions are available and friendlier for healthcare provid-ers and patients. Creating an epistaxis kit with all necessaryinstruments and supplies can help clinicians treat patientsin an organized, stepwise fashion with confidence. Providepatients with written instructions about treating nosebleedsand reducing recurrences. Encourage patients on antico-agulation or oxygen to perform nasal care on a daily basisto prevent epistaxis. JAAPA

Earn Category I CME Credit by reading both CME articles in this issue,

reviewing the post-test, then taking the online test at http://cme.aapa.

org. Successful completion is defined as a cumulative score of at

least 70% correct. This material has been reviewed and is approved

for 1 hour of clinical Category I (Preapproved) CME credit by the

AAPA. The term of approval is for 1 year from the publication date of

November 2014.

REFERENCES

1. Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis andtreatment.J Oral Maxillofac Surg. 2006;64(3):511-518.

2. Pope LE, Hobbs CG. Epistaxis: an update on current manage-ment. Postgrad Med J. 2005;81(955):309-314.

3. Choudhury N, Sharp HR, Mir N, Salama NY. Epistaxis and oralanticoagulant therapy. Rhinology.2004;42(2):92-97.

4. Kilty SJ, Al-Hajry M, Al-Mutairi D, et al. Prospective clinicaltrial of gelatin-thrombin matrix as first line treatment ofposterior epistaxis. Laryngoscope. 2014;124(1):38-42.

5. Mathiasen RA, Cruz RM. Prospective, randomized, controlledclinical trial of a novel matrix hemostatic sealant in patients withacute anterior epistaxis. Laryngoscope.2005;115(5):899-902.

6. Jacobs JR, Levine LA, Davis H, et al. Posterior packs and thenasopulmonary reflex.Laryngoscope. 1981;91(2):279-284.

7. Vitek J. Idiopathic intractable epistaxis: endovascular therapy.Radiology.1991;181(1):113-116.

8. Herkner H, Havel C, Mllner M, et al. Active epistaxis at EDpresentation is associated with arterial hypertension. Am JEmerg Med.2002;20(2):92-95.

9. Herkner H, Laggner AN, Mllner M, et al. Hypertension inpatients presenting with epistaxis. Ann Emerg Med. 2000;35(2):126-130.

10. Thong JF, Lo S, Houghton R, Moore-Gillon V. A prospectivecomparative study to examine the effects of oral diazepam onblood pressure and anxiety levels in patients with acuteepistaxis.J Laryngol Otol. 2007;121(2):124-129.

Moisture is the key to

prevention. Patients with nasal

dryness should use salinenasal spray.