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Hemorrhage from the nose; nosebleed.
SEE: Kiesselbach's area

Most people experience mild nose bleeds during their lives, but more than 400,000 Americans visit ERs annually for epistaxis that does not resolve.

Epistaxis may occur spontaneously or secondary to local infections (vestibulitis, rhinitis, sinusitis), systemic infections (scarlet fever, typhoid), drying of nasal mucous membranes, trauma (including picking the nose), chemical inhalation (esp. tobacco smoke), tumors of the paranasal sinus or nasopharynx, septal perforation, arteriosclerosis, hypertension, and bleeding tendencies associated with anticoagulant drug use, anemia, antiplatelet agents (aspirin, nonsteroidal anti-inflammatory drugs), leukemia, hemophilia, thrombocytopenia, or liver disease.

Epistaxis from the anterior nasal septum is usually mild and easily controlled with firm continuous pressure on the nose and nasal septum for five to ten minutes; bleeding from the posterior nasal cavity cannot usually be controlled with first aid measures at home, often drips into the throat or larynx, and requires professional management. Any bleeding that lasts more than 10 min despite firmly applied pressure to the bleeding source should receive professional care.

In the emergency room, the patient should lean forward slightly and espectorate to avoid swallowing blood and becoming nauseated, and breathe through the mouth while the pressure is maintained for an additional 5 min. Vital signs, a complete blood count, bleeding time, coagulation studies, and type and crossmatch are obtained. Patients who are bleeding vigorously, or those who are hypotensive require intravenous access and fluids. The anterior nasal cavity is examined with a nasal speculum to identify anterior bleeding. Anesthetic/vasoconstricting drugs such as topical cocaine or epinephrine are applied to shrink blood vessels. Cauterization using a silver nitrate stick, electrocautery or petroleum gauze nasal packing may be used for anterior bleeding if a bleeding site is clearly identified. The patient should then lie quietly, propped up at a 45° angle in bed and limit talking. Oral hygiene is provided to remove the taste of blood. The patient and family should be reassured that epistaxis usually looks much worse than it actually is.
SEE: nosebleed for illus

If the bleeding is in the posterior nasal cavity or bleeding from the anterior nasal cavity cannot be controlled, nasal packing, nasal sponges, or inflatable balloons are inserted to tamponade the responsible blood vessels.

Airway clearance and level of discomfort and anxiety are determined. The patient is assured that he or she may breathe through the mouth, with oxygen administered by mask if oximetry demonstrates a need. Antibiotics are typically prescribed if packing is to remain more than 24 hr. Vitamin K or frozen plasma may be used in cases of over-anticoagulation or bleeding disorders. If an artery is bleeding, surgical ligation or embolization and blood transfusion may be required.

After emergent care, the patient should avoid blowing or picking at the nose, removing nasal packing, or bending or lifting weights of more than 5 lb. until the site has healed. All procedures and expected sensations and outcomes are explained to the patient and caregivers. The need for follow-up, usually with an otorhinolaryngologist, to remove packing and inspect the nasal cavity is stressed. Future bleeding episodes may sometimes be prevented by controlling hypertension, carefully monitoring anticoagulation, humidifying ambient air, or avoiding digital trauma to the nose. The patient is shown how to apply anterior pressure to the nostrils to control anterior hemorrhage.

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