Part of what excites us as health care providers is the uncertain. Whether it is in the emergency department, urgent care, or specialty setting, we never know what may walk through the door or what a patient will complain of. In my experience, I learn best when I am thoroughly challenged and brought out of my comfort zone. To the students out there, I encourage you to take on the difficult cases or the chief complaints you do not feel comfortable with.
You are a student on your first rotation, emergency medicine. Despite your didactic training and countless hours of studying, you still feel nervous. The thought of lacerations or complex patients terrify you. Rightfully so! On your third day, you are three minutes into your shift, grabbing a coffee when a young woman runs by you, with an active nose bleed. Thinking you will have to get coffee later, you try to remember the anatomy of the nose and head toward the ED.
As students and clinicians, it is always helpful for us to mentally prepare for what we are about to see. Easier said than done when patients present urgently, but it is always helpful for us to gather our thoughts. As a student, I would read chief complaints or a patient’s disease and try to think of any possible pimping questions that might come up. It paid dividends.
In this case, there are numerous questions we could be faced with, whether we are a student or a clinician. Some important questions that might come up are as follows:
- What is the most common cause of nose bleeds?
- What is the most common anatomical location for nose bleeds?
- What is the difference between anterior and posterior nose bleeds?
- Do anterior nose bleeds need admission to the hospital?
- What labs could be ordered if a patient had frequent nosebleeds?
- Where do posterior nosebleeds usually arise from?
- How can we educate a patient about managing nose bleeds at home?
Nosebleeds are very common reasons for visits to emergency departments, urgent cares, and primary care offices. They can range from benign and self-limiting to severe and even life threatening. Up to 60% of people experience a nose bleed in their life time. (Alter, 2018).
Some of the most likely causes of nose bleeds include trauma as well as digital trauma (to be politically correct). Digital trauma is more common in children, but is the most common cause overall. Other risk factors include allergic rhinitis, anticoagulant use, von Willebrand disease, nasal neoplasms. It is still unclear if hypertension increases the risk for nose bleeds.
A common question in regards to nose bleeds is where is the most common site of bleeding origin. The most common area is Kiesselbach’s Plexus. This is a vascular plexus that is bordered by the anterior ethmoidal artery, sphenopalatine artery, and the greater palatine artery. This is the most common cause of nose bleeds and is an anterior source. Posterior sources generally result in more massive bleeding and are associated with the posterior sinus cavity, particularly the sphenopalatine artery. This is not only a common pimping question, but a great anatomy question!
In all trauma situations, the main concern is airway, breathing, and circulation. Patients with evidence for massive epistaxis should be triaged appropriately and resuscitation guidelines should focus first on identifying life threatening injury.
Once the above has been ruled out or managed, a typical initial approach to the nose bleed includes having the patient blow their nose forcefully to expel clots. The clinician may consider spraying the nares with one spray of oxymetazoline per nostril. Once this is completed, the patient should be instructed to firmly and securely hold the bridge of the nose for 10 to 20 minutes. Peeking to see if bleeding has stopped should not be allowed. Patients should sit with their head slightly forward and advised to remain calm.
If the bleeding still persists, the clinician should perform an exam dedicated to identifying the source of bleeding. The patient should be seated calmly and the clinician should take adequate blood borne precautions (glove, surgical mask). A nasal speculum will provide easy visualization of the nares’ anatomy.
Once a specific origin for the bleeding has been identified, the clinician may attempt to perform topical vasoconstriction. Topical oxymetazoline or phenylephrine may be used. Gauze padding or Gelfoam can be applied for a source of direct pressure. After a period of a few minutes, this can be re-checked and if there is still evidence for bleeding, chemical cautery may be used with silver nitrate.
In the interim, if there is concern that bleeding may be prolonged, lab work that may be ordered includes a CBC, platelet count, type and cross, PT/INR. For frequent nose bleeding, a von Willebrand factor or other clotting factor may be ordered.
If all of the above fails, direct packing can be administered via gauze padding, nasal Tampon, or Rhino Rocket. Balloon devices can also be used. Nasal packing can be left in place for a few days, but should be re-checked by an experienced ENT professional. Some lubricating gel or Bacitracin may be applied to help reduce infection. The decision to pursue prophylactic oral anti-biotics is individualized.
There are possible complications to nasal packing, including the most dreaded Toxic Shock Syndrome. Patients should be educated about the risks and presentations related to this. Additionally, sinusitis, other forms of infection, pain, and pressure necrosis from packing that is too tight, is possible (Kucik and Clenney 2005).
Although most nose bleeds are anterior in origin, posterior nosebleeds raise significant concern, as they have the potential for massive, life-threatening blood loss. Posterior nosebleeds should be managed by an experienced clinician such as an ENT specialist and hospital admission is usually warranted. Due to the significant complexity of specific procedures for managing a posterior nose bleed, synopsis and discussion can be found elsewhere, but embolization, endoscopic intervention may be required.
It is important to note that in posterior nosebleeds, patients may not present with a classic nose bleed. Patients may present with nausea, vomiting, hemoptysis or even hematemesis.
I hope that this article has been helpful in relation to some of the quick pimping facts related to both anterior and posterior epistaxis. Chances are if you do not experience a patient with epistaxis, you may have a personal experience some day. Remember, we always learn best when we are give ourselves the chance to be challenged.
Alter, Harrison (2018). Approach to the adult with Epistaxis. UpToDate, Date of Access 18 November 2018.
Kucik, C.J. and Clenney, T. (2005). Management of Epistaxis. American Family Physician71(2): 305-311.