Epistaxis, also known as nosebleed, is a hemorrhage from the nose caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nose. Usually, the site is the anterior septum, where the three major blood vessels enter the nasal cavity: (1) the anterior ethmoidal artery on the forward part of the roof, (2) the sphenopalatine artery in the posterosuperior region and (3) the internal maxillary branches (the plexus of veins located at the back of the lateral wall under the inferior turbinate); rarely does epistaxis originate in the densely vascular tissue over the turbinates. Causes of epistaxis may include infection, trauma, nose picking, cardiovascular diseases, vigorous nose blowing, nasal tumors, low humidity, inhalation of illicit drugs, blood dyscrasias, a foreign body in the nose, and deviated nasal septum.
Management of epistaxis usually depends on the location of the bleeding site.
- Application of direct pressure: the patient sits upright with the head tilted forward to prevent swallowing and aspiration of blood and is directed to pinch the soft outer portion of the nose against the midline septum for 5 to 10 minutes continuously
- Monitor the vital signs closely
- Assist the patient in the control of bleeding
- Provide tissues or towels and an emesis basin to facilitate expectoration of any excess blood
- Assure the patient that bleeding can be controlled
- Teach ways to prevent epistaxis (straining, high altitudes avoiding forceful nose blowing, and nasal trauma)
- Instruct patient to apply direct pressure to the nose with the thumb and index finger for 15 minutes in the case of recurrence; if cannot be stopped, additional medical attention should be sought, call the doctor on duty and refer the situation
In anterior nosebleeds
- Apply silver nitrate applicator or Gelfoam as ordered
- Electrocautery can be indicated.
- Topical vasoconstriction (adrenaline, cocaine and phenylephrine)
In posterior nosebleeds
- Cotton pledgets soaked in a vasoconstricting solution may be inserted into the nose to reduce blood flow and improve the examiner’s view of the bleeding site
- Cotton tampon may be used to stop the bleeding
- Suction may be used to remove excess blood and clots from the field of inspection
When origin of bleeding is not identified
- A topical anesthetic spray and decongestant agent may be used prior to inserting a gauze packing, or a balloon inflated catheter may be used
- Nose may be packed with gauze covered with petrolatum jelly or antibiotic ointment for 48 hours or up to 5 or 6 days if necessary
- Antibiotics for risks of iatrogenic sinusitis and toxic shock syndrome are given as ordered
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