Definition: Bleeding from the nose. 90% of cases are anterior & involve Kiesselbach’s plexus on the septum. 10% of cases are posterior & arise from a branch of sphenopalatine artery.
• Etiologies include URI (most common), trauma, nose picking, environmental irritants (dry air), intranasal drug use, neoplasm, FB, polyps, anticoagulation/TCP
• RFs: Alcoholism, diabetes, anticoagulation, HTN, hematologic disorder
• Evaluate w/ nasal speculum after having pt blow nose to express clots
• Can usually identify anterior source on exam; posterior bleeds are heavy, brisk, can cause airway compromise. If still bleeding after anterior packing, consider posterior source.
• Check hematocrit if extensive/prolonged bleeding, INR if on warfarin
• If significantly hypertensive, consider antihypertensive to help w/ hemostasis
• Anterior: Start w/ oxymetazoline (Afrin) 3 sprays & hold pressure for 15 min
• May also insert cotton pledgets soaked in cocaine/lidocaine/epinephrine/phenylephrine
• Once vasoconstricted, try to identify a focal bleeding site, then use silver nitrate cautery in ring around bleeding (will not work on active bleeding; caution on septum)
• If bleeding has stopped, observe for 60 min; if recurs, insert a lubricated nasal tampon
• If nasal tampon is not successful, pack the contralateral side. If still unsuccessful, pack bilaterally w/ ¼-in Vaseline gauze accordion-style.
• Posterior: Bleeding can cause airway compromise & be life threatening
• Commercial double balloon device OR pass Foley catheter through nose into posterior pharynx, fill balloon, hold gentle traction
• Anterior: D/c w/ 48 h f/u, typically w/ prophylactic abx for TSS (unproven) (eg, clindamycin, augmentin, or dicloxacillin)
• Posterior: Admit w/ ENT consult