Epistaxis
A common sign, epistaxis (nosebleed) can be spontaneous or induced from the front or back of the nose. Most nosebleeds occur in the anterior-inferior nasal septum (Kiesselbach's plexus), but they may also occur at the point where the inferior turbinates meet the nasopharynx. Usually unilateral, they seem bilateral when blood runs from the bleeding side behind the nasal septum and out the opposite side. Epistaxis ranges from mild oozing to severe — possibly life-threatening — blood loss.
A rich supply of fragile blood vessels makes the nose particularly vulnerable to bleeding. Air moving through the nose can dry and irritate the mucous membranes, forming crusts that bleed when they're removed; dry mucous membranes are also more susceptible to infection, which can produce epistaxis as well. Trauma is another common cause of epistaxis. Additional causes include septal deviations; hematologic, coagulation, renal, and GI disorders; and certain drugs and treatments.
Emergency interventions
If the patient has severe epistaxis, quickly take his vital signs. Be alert for tachypnea, hypotension, and other signs of hypovolemic shock. Insert a large-gauge I.V. line for rapid fluid and blood replacement, and attempt to control bleeding by pinching the nares closed. (However, if you suspect a nasal fracture, don't
pinch the nares. Instead, place gauze under the patient's nose to absorb the blood.)
Have a hypovolemic patient lie down and turn his head to the side to prevent blood from draining down the back of his throat, which could cause aspiration or vomiting of swallowed blood. If the patient isn't hypovolemic, have him sit upright and tilt his head forward. Constantly check airway patency. If the patient's condition is unstable, begin cardiac monitoring and give supplemental oxygen by mask.
History and physical examination
If the patient isn't in distress, take a history. Does he have a history of recent trauma? How often has he had nosebleeds in the past? Have the nosebleeds been long or unusually severe? Has the patient recently had surgery in the sinus area? Ask about a history of hypertension, bleeding or liver disorders, and other recent illnesses. Ask if the patient bruises easily. Find out what drugs he uses, especially anti-inflammatories, such as aspirin, and anticoagulants such as warfarin. Ask about a history of cocaine use.
Begin the physical examination by inspecting the patient's skin for other signs of bleeding, such as ecchymoses and petechiae, and noting jaundice, pallor, or other abnormalities. When examining a trauma patient, look for associated injuries, such as eye trauma or facial fractures.
Medical causes
Aplastic anemia
Aplastic anemia develops insidiously, eventually producing nosebleeds as well as ecchymoses, retinal hemorrhages, menorrhagia, petechiae, bleeding from the mouth, and signs of GI bleeding. Fatigue, dyspnea, a headache, tachycardia, and pallor may also occur.
Barotrauma
Commonly seen in airline passengers and scuba divers, barotrauma may cause severe, painful epistaxis when the patient has an upper respiratory tract infection.
Coagulation disorders
Such coagulation
disorders as hemophilia and thrombocytopenic purpura can cause epistaxis along with ecchymoses, petechiae, and bleeding from the gums, mouth, and I.V. puncture sites. Menorrhagia and signs of GI bleeding, such as melena and hematemesis, can also occur.
Glomerulonephritis (chronic)
Glomerulonephritis
produces nosebleeds as well as hypertension, proteinuria, hematuria, a headache, edema, oliguria, hemoptysis, nausea, vomiting, pruritus, dyspnea, malaise, and fatigue.
Hepatitis
When hepatitis interferes with the clotting mechanism, epistaxis and abnormal bleeding tendencies can result. Associated signs and symptoms typically include jaundice, clay-colored stools, pruritus, hepatomegaly, abdominal pain, a fever, fatigue, weakness, dark amber urine, anorexia, nausea, and vomiting.
Hypertension
Severe hypertension can produce extreme epistaxis, usually in the posterior nose, with pulsation above the middle turbinate. It may be accompanied by dizziness, a throbbing headache, anxiety, peripheral edema, nocturia, nausea, vomiting, drowsiness, and mental impairment.
Leukemia
With acute leukemia, sudden epistaxis is accompanied by a high fever and other types of abnormal bleeding, such as bleeding gums, ecchymoses, petechiae, easy bruising, and prolonged menses. These may follow less-noticeable signs and symptoms, such as weakness, lassitude, pallor, chills, recurrent infections, and a low-grade fever. Acute leukemia may also cause dyspnea, fatigue, malaise, tachycardia, palpitations, a systolic ejection murmur, and abdominal or bone pain.
With chronic leukemia, epistaxis is a late sign that may be accompanied by other types of abnormal bleeding, extreme fatigue, weight loss, hepatosplenomegaly, bone tenderness, edema, macular or nodular skin lesions, pallor, weakness, dyspnea, tachycardia, palpitations, and headache.
Maxillofacial injury
With a maxillofacial injury, a pumping arterial bleed usually causes severe epistaxis. Associated signs and symptoms include facial pain, numbness, swelling, asymmetry, open-bite malocclusion or an inability to open the mouth, diplopia, conjunctival hemorrhage, lip edema, and buccal, mucosal, and soft palate ecchymoses.
Nasal fracture
Unilateral or bilateral epistaxis occurs with nasal swelling, periorbital ecchymoses and edema, pain, nasal deformity, and crepitation of the nasal bones.
Nasal tumor
Blood may ooze from the nose when a tumor disrupts the nasal vasculature. Benign tumors usually bleed when touched, but malignant tumors produce spontaneous unilateral epistaxis, along with a foul discharge, cheek swelling, and — in the late stage — pain.
Polycythemia vera
A common sign of polycythemia vera, spontaneous epistaxis may be accompanied by bleeding gums; ecchymoses; ruddy cyanosis of the face, nose, ears, and lips; and congestion of the conjunctiva, retina, and oral mucous membranes. Other signs and symptoms vary according to the affected body system, but may include a headache, dizziness, tinnitus, vision disturbances, hypertension, chest pain, intermittent claudication, early satiety and fullness, marked splenomegaly, epigastric pain, pruritus, and dyspnea.
Sarcoidosis
Oozing epistaxis may occur in sarcoidosis, along with a nonproductive cough, substernal pain, malaise, and weight loss. Related findings include tachycardia, arrhythmias, parotid enlargement, cervical lymphadenopathy, skin lesions, hepatosplenomegaly, and arthritis in the ankles, knees, and wrists.
Scleroma
With scleroma, oozing epistaxis occurs with a watery nasal discharge that becomes foul-smelling and crusty. Progressive anosmia and turbinate atrophy may also occur.
Sinusitis (acute)
With sinusitis, a bloody or blood-tinged nasal discharge may become purulent and copious after 24 to 48 hours. Associated signs and symptoms include nasal congestion, pain, tenderness, malaise, a headache, a low-grade fever, and red, edematous nasal mucosa.
Skull fracture
Depending on the type of fracture, epistaxis can be direct (when blood flows directly down the nares) or indirect (when blood drains through the eustachian tube and into the nose). Abrasions, contusions, lacerations, or avulsions are common. A severe skull fracture may cause a severe headache, a decreased level of consciousness, hemiparesis, dizziness, seizures, projectile vomiting, and decreased pulse and respiratory rates.
A basilar fracture may also cause bleeding from the pharynx, ears, and conjunctiva as well as raccoon eyes and Battle's sign. Cerebrospinal fluid or even brain tissue may leak from the nose or ears. A sphenoid fracture may also cause blindness, whereas a temporal fracture may also cause unilateral deafness or facial paralysis.
Systemic lupus erythematosus (SLE)
Usually affecting women younger than age 50, SLE causes oozing epistaxis. More characteristic signs and symptoms include butterfly rash, lymphadenopathy, joint pain and stiffness, anorexia, nausea, vomiting, myalgia, and weight loss.
Typhoid fever
Oozing epistaxis and a dry cough are common. Typhoid fever may also cause an abrupt onset of chills and a high fever, vomiting, abdominal distention, constipation or diarrhea, splenomegaly, hepatomegaly, “rose-spot” rash, jaundice, anorexia, weight loss, and profound fatigue.
Other causes
Chemical irritants
Some chemi-cals — including phosphorus, sulfuric acid, ammonia, printer's ink, and chromates — irritate the nasal mucosa, producing epistaxis.
Drugs
Anticoagulants, such as warfarin, and anti-inflammatories, such as aspirin, can cause epistaxis. Cocaine use, especially if frequent, can also cause epistaxis.
Surgery and procedures
Rarely, epistaxis results from facial and nasal surgery, including septoplasty, rhinoplasty, antrostomy, endoscopic sinus procedures, orbital decompression, and dental extraction.
Special considerations
Until the bleeding is completely under control, continue to monitor the patient for signs of hypovolemic shock, such as tachycardia and clammy skin. If external pressure doesn't control the bleeding, insert cotton that has been impregnated with a vasoconstrictor and local anesthetic into the patient's nose.
If bleeding persists, expect to insert anterior or posterior nasal packing. (See Controlling epistaxis with nasal packing.) Administer humidified oxygen by face mask to a patient with posterior packing.
A complete blood count may be ordered to evaluate blood loss and detect anemia. Clotting studies, such as prothrombin time and partial thromboplastin time, may be required to test coagulation time. Prepare the patient for X-rays if he has had a recent trauma.
Pediatric pointers
Children are more likely to experience anterior nosebleeds, usually the result of nose-picking or allergic rhinitis. Biliary atresia, cystic fibrosis, hereditary afibrinogenemia, and nasal trauma due to a foreign body can also cause epistaxis. Rubeola may cause an oozing nosebleed along with the characteristic maculopapular rash. Two rare childhood diseases — pertussis and diphtheria — can also cause oozing epistaxis.
Suspect a bleeding disorder if you see excess umbilical cord bleeding at birth or profuse bleeding during circumcision. Epistaxis commonly begins at puberty in patients with hereditary hemorrhagic telangiectasia.
Geriatric pointers
Elderly patients are more likely to have posterior nosebleeds.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Nosebleeds
Read excerpts from these other book chapters related to Nosebleeds:
Medical Books Excerpts
- EPISTAXIS
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- HEMOPTYSIS
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- EPISTAXIS
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
- Epistaxis
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Hemoptysis
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Epistaxis
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
- Epistaxis
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Hemoptysis
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Hemoptysis
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Nosebleed
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Hemoptysis
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Epistaxis
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Hemoptysis
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Epistaxis
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
- Hemoptysis
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
- Epistaxis
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- EPISTAXIS
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Nosebleeds
» Next page: Hemoptysis (Handbook of Signs & Symptoms (Third Edition))
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