Epistaxis Clinical Overview

Written By Danial Mirza

I. The "On-Call" Snapshot

  • Clinical Significance in Malaysia: This is a bread-and-butter ENT and Emergency Department presentation. You need to be able to differentiate a simple anterior bleed from a dangerous posterior one and manage it effectively without draining hospital resources.

  • High-Yield Definition: Epistaxis is acute hemorrhage from the nostril, nasal cavity, or nasopharynx. It is broadly divided into anterior and posterior bleeding based on the anatomical source.

  • Clinical One-Liner: Basically, it's a nosebleed. 90% are from the front of the nose and easy to stop; the 10% from the back are the ones that can cause serious trouble.

II. Etiology & Risk Factors

  • Etiology: Can be divided into local and systemic causes.

    • Local (Most Common):

      • Idiopathic (85% of cases).

      • Digital trauma (nose picking).

      • Facial trauma.

      • Inflammatory/Infectious: Allergic rhinitis, sinusitis.

      • Anatomical: Septal deviation, perforation.

      • Neoplasms (rare, but a key red flag for unilateral, persistent epistaxis).

    • Systemic:

      • Anticoagulants (Warfarin) / Antiplatelets (Aspirin, Clopidogrel).

      • Hypertension (more a factor for prolonging bleeding than starting it).

      • Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu syndrome).

      • Coagulopathies (e.g., von Willebrand disease, hemophilia, liver failure).

  • Risk Factors:

    • Modifiable: Use of NSAIDs, aspirin, clopidogrel, warfarin; uncontrolled hypertension; cocaine use; alcohol abuse.

    • Non-Modifiable: Age (>50 years), dry climate (air-conditioning), inherited coagulopathies.

III. Quick Pathophysiology

The nasal cavity has a rich, dual-artery blood supply from both the internal and external carotids.

  • Anterior Bleeds (~90%): Originate from Kiesselbach's plexus (also called Little's Area) on the anterior nasal septum. This is an anastomosis of several arteries. Bleeding here is usually a steady, venous-like ooze and responds well to direct pressure.

  • Posterior Bleeds (~10%): Originate from the posterior septal nasal artery, a branch of the sphenopalatine artery. This is a higher-pressure, arterial bleed. Blood will flow down the pharynx, and it will not stop with simple anterior pressure. These are the patients who need admission and ENT intervention.

IV. Clinical Assessment

  • Red Flags & Immediate Actions:

    • Hemodynamic Instability (Tachycardia, Hypotension): -> Alert senior immediately. Secure two large-bore IV cannulas, send GXM, and start fluid resuscitation with normal saline.

    • Posterior Bleeding (blood in pharynx, bilateral nares bleeding): -> Alert senior/ENT. Patient must be NBM (Nil By Mouth). Keep patient sitting upright and leaning forward.

    • Concomitant Major Trauma (especially head injury): -> Suspect skull base fracture. Do not insert a nasal pack. C-spine precautions. Manage according to ATLS principles. Call the relevant surgical teams.

    • Known Coagulopathy or on Warfarin with INR > 3: -> Alert senior. Plan for reversal (Vitamin K, Prothrombinex Complex Concentrate) based on local hospital protocol.

  • History:

    • Common (>50%): Unilateral bleeding, history of minor nose-picking/trauma, recurrent minor bleeds.

    • Less Common (10-50%): Bleeding post-sneezing/coughing, symptoms of rhinitis/sinusitis.

    • Rare (<10%): Purulent discharge, facial pain, nasal obstruction (suggests neoplasm), family history of bleeding disorders, easy bruising.

    • Pertinent Negatives: Ask about anticoagulant/antiplatelet use. Ask about previous episodes and what was done. Ask about symptoms of anemia like fatigue or dyspnea on exertion.

  • Physical Examination:

    • Preparation is key: Get proper PPE (gloves, gown, face shield - it can get messy), a headlight, a nasal speculum (a Thudichum's is standard), and suction.

    • General: Assess for signs of shock (pallor, sweating, confusion). Check vital signs.

    • Nose (Anterior Rhinoscopy):

      1. Ask the patient to blow their nose gently to clear clots.

      2. Spray with a topical vasoconstrictor and local anesthetic (e.g., Co-phenylcaine or 0.05% Oxymetazoline). Wait a few minutes.

      3. Inspect Little's Area on the anterior septum for an active bleeding point or visible vessel.

    • Oropharynx: Check the posterior pharynx for blood trickling down. This is the cardinal sign of a posterior bleed.

    • Systemic: Look for skin signs of bleeding disorders like petechiae, purpura, or telangiectasias on the lips/tongue (HHT).

  • Clinical Pearl: Don't be afraid to get the patient to blow their nose. Removing the clots is essential to stop the bleeding, as fibrinolysis within the clot promotes more bleeding. A big clot is your enemy.

V. Diagnostic Workflow

  • Differential Diagnosis:

    • Haemoptysis:

      • Points For: Patient coughing up blood.

      • Points Against: No visible bleeding source in the nose, blood is often frothy.

      • How to Differentiate: Good clinical history and examination. A chest X-ray may be needed.

    • Hematemesis:

      • Points For: Patient vomiting blood, history of liver disease or PUD.

      • Points Against: No active nasal bleeding seen on examination.

      • How to Differentiate: History. Blood is often coffee-ground in appearance. Check for melaena.

  • Investigations Plan:

    • Bedside / Initial (First 15 Mins): Not usually needed for simple, self-limiting epistaxis. For severe or posterior bleeds, get IV access and a VBG to check Hb and lactate.

    • First-Line Labs & Imaging (for severe, posterior, or recurrent bleeds):

      • FBC: To assess degree of blood loss and check platelet count.

      • Coagulation Profile (PT/INR, APTT): Essential if the patient is on anticoagulants or has a history of liver disease/bleeding disorders.

      • Group & Cross Match (GXM): Mandatory for any hemodynamically unstable patient or those with severe, ongoing bleeding.

    • Confirmatory / Gold Standard:

      • Nasal Endoscopy: Performed by ENT to directly visualize the bleeding source, especially for posterior bleeds. This is both diagnostic and therapeutic.

VI. Staging & Severity Assessment

Assessment is clinical, based on hemodynamic status and control of bleeding.

  • Simple/Uncomplicated Epistaxis: Anterior bleed, hemodynamically stable, bleeding stops with first aid or simple cautery. Manageable in the ED.

  • Complex/Severe Epistaxis:

    • Posterior bleed.

    • Bleeding despite initial measures (pressure, cautery).

    • Hemodynamic instability.

    • Requires nasal packing.

    • Impact on Management: All patients with complex epistaxis require admission under the ENT team for observation and possible surgical intervention.

VII. Management Plan

  • Immediate Stabilisation (The ABCDE Plan):

    1. Airway: Ensure the airway is patent. Encourage the patient to sit up and lean forward to prevent aspiration.

    2. Breathing: Administer high-flow oxygen (10-15L/min via non-rebreather mask) if there are signs of shock.

    3. Circulation:

      • Apply direct pressure by pinching the soft, cartilaginous part of the nose continuously for 15-20 minutes.

      • If bleeding is severe, establish IV access and begin fluid resuscitation.

    4. Disability/Exposure: Assess GCS.

  • Definitive Treatment (The Ward Round Plan):

    • First-Line (Anterior Bleed):

      1. Pressure: As above.

      2. Topical Agents: Apply a cotton pledget soaked in a vasoconstrictor/anesthetic.

      3. Chemical Cautery: If a bleeding point is visible, apply a silver nitrate stick to the area for 5-10 seconds, starting from the periphery and moving centrally. Do NOT cauterize both sides of the septum at the same time to avoid perforation.

    • Second-Line / Refractory Cases (Requires ENT input):

      1. Anterior Nasal Packing: If cautery fails or the bleeding point isn't seen. Use a prefabricated nasal tampon (e.g., Merocel). Coat with antibiotic ointment (e.g., Chloramphenicol), insert along the floor of the nose, and hydrate it with saline. The patient must be admitted.

      2. Posterior Nasal Packing: Done by ENT, often with a Foley catheter or specialized balloon pack. These patients often need admission to a high-dependency setting due to the risk of vagal stimulation and airway compromise.

      3. Surgical Intervention: Endoscopic sphenopalatine artery ligation (SPA ligation) or anterior ethmoidal artery ligation are definitive treatments for refractory posterior bleeds.

  • Long-Term & Discharge Plan:

    • Nasal Care: Advise the patient to avoid nose blowing, straining, and hot food/drinks for the next 48-72 hours.

    • Moisturisation: Saline nasal spray or a simple emollient can help prevent mucosal drying.

    • Medication Review: Address underlying causes. Does their antihypertensive need adjusting? Can their antiplatelet be temporarily withheld? Discuss with the primary team or specialist.

    • Follow-up: For patients who had packing, arrange for removal in 24-48 hours at the ENT clinic.

VIII. Complications

  • Immediate:

    • Hemorrhagic Shock: Management: Aggressive fluid resuscitation and blood transfusion.

    • Aspiration: Management: Keep patient sitting forward.

    • Complications of Packing (Pain, Hypoxia): Management: Adequate analgesia. Monitor oxygen saturation.

  • Short-Term:

    • Toxic Shock Syndrome (from packing): Management: Remove pack, give IV antibiotics. This is why packs are removed within 48 hours.

    • Septal Perforation/Hematoma (from overzealous cautery/packing): Management: ENT referral.

  • Long-Term:

    • Anemia: Management: Oral iron supplementation.

    • Recurrence: Management: Address underlying risk factors, consider referral for elective cautery.

IX. Prognosis

  • Excellent for the vast majority of simple anterior epistaxis.

  • Mortality is very low but is associated with severe posterior bleeds in elderly patients with significant comorbidities, primarily from cardiovascular complications or aspiration.

  • Top 3 Prognostic Factors: Age, posterior source of bleed, and presence of comorbidities/anticoagulant use.

X. How to Present to Your Senior

"Dr., for review please. This is [Patient's Name] in ED Resus Bay 2, a [age]-year-old [man/woman] on Warfarin for atrial fibrillation, who presented with a severe nosebleed for the past hour.

On assessment, he is tachycardic at 110, BP 100/60. He has ongoing bleeding with blood visible in his posterior pharynx, consistent with a posterior bleed.

I have applied first aid pressure with minimal effect. We have secured two large-bore IVs, sent FBC, Coags, and GXM, and started a fluid bolus. My main concern is a posterior bleed with hemodynamic compromise in the setting of anticoagulation. I would like to request an urgent ENT review for potential nasal packing and discuss reversal of his Warfarin."

XI. Summary & Further Reading

  • Top 3 Takeaways:

    1. Sit the patient up, lean them forward, and pinch the soft part of the nose for 15-20 minutes. This works for most cases.

    2. Always check the back of the throat for trickling blood. This is the key sign of a dangerous posterior bleed that needs escalation.

    3. Do not cauterize both sides of the septum in the same sitting. You risk causing a septal perforation.

  • Key Resources:

Danial Mirza
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