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Epistaxis is a common occurrence, affecting 60% of the population at some point during their lifetime.1,2 The patients who seek medical attention are most commonly under 10 years of age and over 50 years of age.1,2 Common causes of epistaxis include digital trauma, a deviated septum, dry air exposure (lack of humidity), rhinosinusitis, neoplasia, or chemical irritants such as inhaled corticosteroids or chronic nasal cannula oxygen use.3 Systemic factors that increase the risk of bleeding include chronic renal insufficiency, alcoholism, hypertension, vascular malformations such as hereditary hemorrhagic telangiectasia, any kind of coagulopathy, anticoagulation use, von Willebrand’s disease, and hemophilia.3


The superior labial branch of the facial artery joins the anterior ethmoidal and terminal branch of the sphenopalatine artery to form Kiesselbach plexus on the anterior nasal septum, which is the source of 90% of nosebleeds and can usually be visualized with anterior rhinoscopy (Figure 244-1). The most likely source for posterior bleeds is the sphenopalatine artery, which is a terminal division of the internal maxillary artery (branch of the external carotid system). Endoscopic or open surgical techniques are needed to visualize the vessel.3,4 Sensory innervation is detailed in Figure 244-2.

FIGURE 244-1.

Arterial blood supply to the nasal cavity. The most common site of nasal hemorrhage is at Little’s area of the nasal septum. The most common origin of posterior epistaxis is from the sphenopalatine artery.

FIGURE 244-2.

Sensory innervation of the external nose. [Reproduced with permission from Reichman EF, Simon RR: Emergency Medicine Procedures. © 2004, Eric F. Reichman, PhD, MD, and Robert R. Simon, MD.]


Identify an anterior or posterior source of acute epistaxis with a directed history and physical examination. Ask about previous or recurrent epistaxis as well as duration and severity of the episode. Collect history concerning alcohol, drug, or medication use especially NSAID, anticoagulation, antiplatelet, or aspirin use. Review any history of trauma, prior head and neck procedures, and a personal and family history of coagulopathy.

The evaluation and management of the patient with epistaxis will be much easier and efficient if your department has a well-stocked and easily accessed ear, nose, and throat (ENT) procedure tray, kit, or cart so that you can examine the patient and attempt to control the bleeding. The kit should include a nasal speculum, bayonet forceps, headlamp, suction catheter, cotton pledgets, 0.05% oxymetazoline and 4% lidocaine solutions, silver nitrate swabs, and some combination of absorbable and nonabsorbable materials for anterior and posterior packing.

If there is active bleeding, wear gloves, gown, and facemask with eye shield. Assemble ...

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