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