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Epistaxis occurs most frequently in children under 10 years old and in those over 70 years old.1 Local causes of epistaxis include digital trauma, a deviated septum, dry air exposure, rhinosinusitis, neoplasia, or chemical irritants such as inhaled corticosteroids or chronic nasal cannula oxygen use. Systemic factors that increase the risk of bleeding include chronic renal insufficiency, alcoholism, hypertension, vascular malformations such as hereditary hemorrhagic telangiectasia, or any kind of coagulopathy, including warfarin administration, von Willebrand's disease, or hemophilia.2


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.2,3 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.]


A directed history and physical examination is usually sufficient to identify the source of acute epistaxis. Ask about prior or recurrent epistaxis, duration and severity of the current episode, and laterality. Ask specifically about nonsteroidal anti-inflammatory drugs, warfarin, heparin, or aspirin use. Alcohol or cocaine abuse, trauma, prior head and neck procedures, and a personal and family history of coagulopathy should be assessed.

Make preparations for nasal examination and tamponade. The ED should have a preprepared, readily available epistaxis kit or cart. 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.

Assemble a good light source, suction, and a nasal speculum. Have the patient seated and in the "sniffing" position. The sniffing position is achieved by having the patient flex and extend the head while keeping the base of the nose straight ahead. With the patient in this position, brace the speculum by resting the index finger on the tip of the nose and insert the speculum with the handle ...

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