Epistaxis is bleeding from the nose, commonly from the anterior-inferior nasal septum (Kiesselbach’s plexus), but it may also occur posteriorly near the inferior turbinates or nasopharynx. It can range from mild oozing to life-threatening hemorrhage and is usually unilateral, though bilateral bleeding may appear if blood flows behind the septum.

Pathophysiology

• Fragile blood vessels in the nasal mucosa make the nose prone to bleeding.

• Dry air, infection, trauma, or local irritants can damage mucosa.

• Systemic conditions (coagulation disorders, hypertension, liver disease) may exacerbate bleeding.

History and Physical Examination

History:

• Onset, frequency, duration, and severity of bleeding

• Recent trauma, surgery, or instrumentation

• Hypertension, liver, renal, hematologic disorders

• Medication history: anticoagulants, antiplatelets, NSAIDs, cocaine

• Family history of bleeding disorders

Physical Examination:

• Inspect skin for ecchymoses, petechiae, jaundice, pallor

• Examine nose for deformities, swelling, septal deviations, foreign bodies

• Evaluate for systemic bleeding or trauma-related injuries

Medical Causes

Other Causes:

• Chemical irritants: phosphorus, acids, ammonia, printer ink

• Drugs: anticoagulants, NSAIDs, cocaine

• Surgical procedures: septoplasty, rhinoplasty, sinus surgery, dental extraction

• Pediatric-specific: nose picking, allergic rhinitis, cystic fibrosis, hereditary bleeding disorders, rubeola, pertussis, diphtheria

• Geriatric-specific: more posterior nosebleeds

Emergency Interventions

• Assess vital signs; look for tachycardia, hypotension, hypovolemic shock

• Establish IV access for fluids and blood replacement

• Position patient: upright and leaning forward if stable; supine with head to side if hypovolemic

• Pinch nares for 10 minutes (unless nasal fracture suspected)

• Monitor airway and oxygenation; provide supplemental oxygen if needed

• Use topical vasoconstrictors or local anesthetics if pressure fails

• Consider anterior or posterior nasal packing for uncontrolled bleeding

Special considerations for nasal packing

• Anterior: petroleum gauze strips for anterior bleeding

• Posterior: gauze pack or indwelling catheter behind soft palate secured with sutures

• Monitor for respiratory distress, hypoxia, or airway obstruction

• Avoid nose blowing for 48 hours after pack removal

• Administer humidified oxygen if needed

Patient Counseling

• Teach pinching technique and proper head positioning

• Discuss avoidance of nasal trauma or irritants

• Advise on medications that increase bleeding risk

• Encourage monitoring for recurrent or severe nosebleeds

Pediatric Pointers

• More likely anterior nosebleeds due to trauma, nose picking, or rhinitis

• Rare causes: cystic fibrosis, hereditary afibrinogenemia, biliary atresia, foreign body, rubeola, pertussis, diphtheria

• Bleeding disorders should be suspected in excessive cord bleeding at birth or circumcision

Geriatric Pointers

• More prone to posterior epistaxis

• Often related to hypertension, anticoagulants, or fragile nasal mucosa

References:

1. Camp AA, Dutton JM, Caldarelli DD. Endoscopic transnasal transethmoid ligation of the anterior ethmoid artery. Am J Rhinol Allergy. 2009;23(2):200–202.

2. Dallan I, Tschabitscher M, Castelnuovo P, Bignami M, Muscatello L, Lenzi R, et al. Management of severely bleeding ethmoidal arteries. J Craniofac Surg. 2009;20(2):450–454.