Chapter 148

Epistaxis is an extremely common condition in the United States with an incidence estimated at 10 per 10,000 people per year.1 It is a common reason for patient visits to the Emergency Department. Epistaxis usually is the result of well-localized intranasal trauma. However, it may be the initial sign of a more serious underlying systemic illness. Epistaxis is often self-limited and can be managed conservatively. Epistaxis can also manifest itself as a profuse spontaneous hemorrhage that is extremely difficult to control and result in aspiration, hypotension, cardiovascular collapse, syncope, and airway compromise.

The proper management of epistaxis and the prevention of adverse consequences depend on a timely and thorough evaluation of the patient as well as the appropriate intervention. The Emergency Physician must be familiar with a variety of techniques that can be used to control intranasal hemorrhage.

An understanding of the vascular anatomy of the nasal cavity is essential to efficient and immediate control of nasal bleeding. The blood supply to the sinonasal cavity arises from both the internal and external carotid artery system (Figure 148-1). The sphenopalatine artery arises as one of the terminal branches of the internal maxillary artery, a branch of the external carotid system, and is the primary blood supply to the sinonasal cavities. The anterior and posterior ethmoid arteries, terminal branches of the internal carotid system, supply blood to the superior straits of the nose. The superior labial branch of the facial artery supplies the anterior nasal cavity and anastomoses with branches from the anterior ethmoid artery and the sphenopalatine artery in an area of the anterior nasal septum known as Kiesselbach’s plexus or Little’s area (Figure 148-2). It has been estimated that 90 percent of all nasal bleeding occurs in this area.2 This is particularly true for children and young adults. Older adults tend to bleed from the posterior nasal cavity, from branches of the sphenopalatine and posterior ethmoidal arteries. This has been attributed to arteriosclerosis.2

###### Figure 148-1

The blood supply of the nasal cavity arises from the internal and external carotid artery systems.

###### Figure 148-2

The anterior ethmoid artery and the sphenopalatine arteries supply the anterior nasal septum and Kiesselbach’s plexus.

Epistaxis may result from numerous local and/or systemic factors that damage the delicate mucosal lining of the nasal cavity and expose the underlying vasculature. The most common cause of epistaxis is accidental or self-inflicted trauma, often from digital manipulation of the nasal mucosa (i.e., nose picking). This eventually heals and crusts over but is subject to repeated irritation and bleeding when the patient sneezes or blows their nose. The anterior source of this bleeding makes it very easy to treat. High-velocity trauma to the region of the midface and skull ...

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