Epistaxis
Epistaxis, commonly known as a nosebleed, may be a primary disorder or may occur secondary to another condition. Such bleeding in children generally originates in the anterior nasal septum and tends to be mild. In adults, such bleeding is most likely to originate in the posterior septum and can be severe. Epistaxis is twice as common in children as in adults.
Causes
Epistaxis usually follows trauma from external or internal causes: a blow to the nose, nose picking, or insertion of a foreign body; low humidity; or allergies, colds, or sinusitis. Less commonly, it follows polyps; acute or chronic infections such as sinusitis or rhinitis, which cause congestion and eventual bleeding of the capillary blood vessels; or inhalation of chemicals that irritate the nasal mucosa.
Predisposing factors include anticoagulant therapy, hypertension, long-term use of aspirin, high altitudes and dry climates, sclerotic vessel disease, Hodgkin’s disease, hereditary hemorrhagic telangiectasia, neoplastic disorders (such as juvenile nasopharyngeal angiofibromas), scurvy, vitamin K deficiency, rheumatic fever, and blood dyscrasias (hemophilia, purpura, leukemia, and anemias).
Signs and symptoms
Blood oozing from the nostrils usually originates in the anterior nose and is bright red. Blood from the back of the throat originates in the posterior area and may be dark or bright red (commonly mistaken for hemoptysis due to expectoration). Epistaxis is generally unilateral, except when it’s due to dyscrasia or severe trauma. In severe epistaxis, blood may seep behind the nasal septum; it may also appear in the middle ear and in the corners of the eyes.
Associated clinical effects depend on the severity of bleeding. Moderate blood loss may produce light-headedness, dizziness, and slight respiratory difficulty; severe hemorrhage causes hypotension, rapid and bounding pulse, dyspnea, and pallor. Bleeding is considered severe if it persists longer than 10 minutes after pressure is applied and causes blood loss as great as 1 L/hour in adults. Exsanguination (bleeding to death) from epistaxis is rare.
Diagnosis
CONFIRMING DIAGNOSIS Although simple observation confirms epistaxis, inspection with a bright light and a nasal speculum is necessary to locate the site of bleeding.
Relevant laboratory values include:
❑ gradual reduction in hemoglobin levels and hematocrit (HCT; usually inaccurate immediately following epistaxis because of hemoconcentration)
❑ decreased platelet count in the patient with blood dyscrasia
❑ prothrombin time and partial thromboplastin time showing a coagulation time twice the control, because of a bleeding disorder or anticoagulant therapy.
Diagnosis must rule out underlying systemic causes of epistaxis, especially disseminated intravascular coagulation and rheumatic fever. Bruises or concomitant bleeding elsewhere probably indicates a hematologic disorder.
PEDIATRIC TIP Bleeding tests are indicated if any of the following are present:
❑ family history of a bleeding disorder
❑ medical history of easy bleeding
❑ spontaneous bleeding at other sites
❑ bleeding that won’t clot with direct pressure by the physician
❑ bleeding that lasts longer than 30 minutes
❑ onset before age 2 or a drop in HCT due to epistaxis.
Treatment
Mild nosebleeds that occur spontaneously may be treated by gently squeezing the soft portion of the nose between the thumb and finger for 5 to 10 minutes while the patient leans forward slightly (to avoid swallowing the blood) and breathes through his mouth.
For anterior bleeding, treatment consists of application to the bleeding site of a cotton ball saturated with epinephrine, and external pressure, followed by cauterization with electrocautery or a silver nitrate stick. If these measures don’t control the bleeding, petroleum gauze nasal packing may be needed.
For posterior bleeding, therapy includes gauze packing inserted through the nose, or postnasal packing inserted through the mouth, depending on the bleeding site. (Gauze packing generally remains in place for 24 to 48 hours; postnasal packing, 3 to 5 days.) (See Inserting an anterior-posterior nasal pack.) An alternate method, the nasal balloon catheter, also controls bleeding effectively. Antibiotics may be appropriate if packing must remain in place for longer than 24 hours. If local measures fail to control bleeding, additional treatment may include supplemental vitamin K and, for severe bleeding, blood transfusions and surgical ligation or embolization of a bleeding artery.
Special considerations
To control epistaxis:
❑ Elevate the patient’s head 45 degrees.
❑ Continuously compress the soft portion of the nares against the septum for 5 to10 minutes. Apply an ice collar or cold, wet compresses to the nose. If bleeding continues after 10 minutes of pressure, notify the physician.
❑ Administer oxygen as needed, and monitor saturation levels.
❑ Monitor vital signs and skin color; record blood loss.
❑ Tell the patient to breathe through his mouth and not to swallow blood, talk, or blow his nose.
❑ Keep vasoconstrictors, such as phenylephrine, handy.
❑ Reassure the patient and his family that epistaxis usually looks worse than it is.
To prevent recurrence of epistaxis:
❑ Instruct the patient not to pick his nose or insert foreign objects into it, and to avoid bending or lifting. Emphasize the need for follow-up examinations and periodic blood studies after an episode of epistaxis. Advise prompt treatment for nasal infection or irritation.
❑ Suggest humidifiers for people who live in dry climates or at high elevations, or whose homes are heated with circulating hot air.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 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: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Nosebleeds
» Next page: Fractured nose (Professional Guide to Diseases (Eighth Edition))
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