CME

Managing epistaxis
Linda Diamond, PA-C

ABSTRACT
An estimated 60% of the population will have a nosebleed
in their lifetime, and 6% will require medical intervention. Uncontrolled nasal bleeding can lead to hypovolemia
and airway compromise. Understanding prevention and
management of epistaxis is especially important to clinicians who manage patients on anticoagulants, supplemental
oxygen therapy, or who have other risk factors for epistaxis.
This article reviews stepwise management for epistaxis and
newer treatment options in adults.
Keywords: epistaxis, nosebleeds, nasal packing, thrombogenic agents, balloon catheter, anticoagulation

Learning objectives
Identify risk factors and causes of epistaxis.
Describe the stepwise management of epistaxis.
List the equipment and medications needed to
manage epistaxis.

pistaxis is defined as acute hemorrhage from the

nostril, nasal cavity, or nasopharynx. Nosebleeds
are a common condition and most are selflimiting. However, uncontrolled nasal bleeding can lead
to hypovolemia and airway compromise. This article
reviews the risk factors, prevention, and management
of epistaxis, including management for patients on
anticoagulants or supplemental oxygen. Newer treatment options offer patients and clinicians a better
arsenal to treat epistaxis.
CAUSES
Epistaxis is a frequent phenomenon. An estimated 60%
of the population will have a nosebleed in their lifetime,
and 6% require medical intervention.1,2 The incidence of
epistaxis is a bimodal distribution, peaking in young
children and again in adults ages 45 to 65 years.2 Epistaxis
Linda Diamond practices ENT head and neck surgery at Allegheny
General Hospital in Pittsburgh, Pa. The author has disclosed no
potential conflicts of interest, financial or otherwise.
DOI: 10.1097/01.JAA.0000455643.58683.26
Copyright 2014 American Academy of Physician Assistants

JAAPA Journal of the American Academy of Physician Assistants

FIGURE 1. Anatomy of the nasal cavity

can be caused by a variety of factors (Table 1). Anticoagulation, underlying liver disorders, or other blood
coagulopathies can contribute to the inability to control
epistaxis. Recurrent or unilateral epistaxis along with
nasal congestion or nasal obstruction, independent of the
degree of bleeding, may indicate nasal neoplasm.
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35

CME

Key points
An estimated 60% of the population will have epistaxis at
some time, and 6% will require medical treatment.
Newer options for nasal packing and thrombogenic
materials are less traumatic for patients and healthcare
professionals.
Patients on anticoagulant or antiplatelet medications
should be instructed in nasal care to reduce the risk of
epistaxis.
An epistaxis kit of necessary instruments and supplies may
help healthcare providers treat patients more efficiently
and effectively.

ANATOMY
The nasal cavitytwo chambers divided by the nasal
septumwarms and moistens the air we breathe. The
septum is lined by mucous membrane and contains a
rich vascular supply generating from branches of the
internal and external carotid arteries. More than 90%
of cases of epistaxis occur on the nasal septum in the
vascular area called the Kiesselbach plexus.1 This area
is prone to digital trauma and excessive drying, and is
exacerbated by the use of supplemental oxygen via nasal
cannula. The Kiesselbach plexus is supplied by both the
anterior and posterior ethmoid arteries as well as
branches from the sphenopalatine and greater palatine
arteries (Figure 1). Epistaxis in this area is defi ned
as anterior and is generally self-limiting and easier to
control.
The lateral wall of the nasal cavity is more complex, with
three bony elevations called turbinates or conchae. These
conchae are covered with a thick mucous membrane and
increase the surface area to moisten inhaled air. Posterior
nasal cavity epistaxis occurs in 5% to 10% of nasal bleeding.1 Branches of the internal maxillary artery (sphenopalatine and descending palatine arteries) with a small
contribution from the posterior ethmoid artery make up
the vascular supply to this area. Posterior epistaxis is often
more difficult to visualize and to reach anatomically,
therefore, more difficult to control.1,2
HISTORY AND ASSESSMENT
Obtaining a timeline of the patients nosebleed is important;
the duration of the bleeding may indicate whether the
patient needs more emergent treatment. Refer the patient
to the nearest ED if he or she has had recurrent hard-tocontrol bleeding over several days or a single significant
bleed lasting longer than 1 hour.
Review the patients medical history, looking for
chronic medical conditions that may predispose the
patient to bleeding, such as hypertension, liver disease,
heart disease, or blood disorders. Note and document
if the patient is taking anticoagulants or antiplatelet
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TABLE 1.

Causes of epistaxis

Traumatic
Nose picking
Facial injury
Foreign body
Nasogastric tube placements
Barotrauma
Neoplastic
Benign
Malignant
Hematologic
Thrombocytopenia
Hemophilia
Von Willebrand disease
Hereditary hemorrhagic telangiectasia
Hepatic diseases
Anticoagulant or antiplatelet medications
Structural
Dryness
Septal perforation
Surgical procedures
Drug-induced
Nasal sprays
Substance inhalation
Inflammatory
Environmental irritants
Allergic rhinitis
Infections

drugs such as aspirin and nonsteroidal anti-inflammatory

drugs (NSAIDs).
In the initial evaluation of a patient with epistaxis, focus
on airway competency and cardiovascular stability. Patients
with severe bleeding may need resuscitation and airway
control. Be sure to have adequate lighting when inspecting
the nasal cavity in the office setting. A headlight source with
a nasal speculum is recommended. Inexpensive headlamps
used for camping or recreation can provide a narrow tight
beam, allowing better visualization and freeing both of the
healthcare providers hands. The patient should be sitting
upright on examination chair or table to limit head movement.
An epistaxis kit containing all the necessary instruments
and packing is helpful (Table 2). Bayonet forceps or straight
sturdy blunt-ended tweezers about 8 in long are used to insert
pledgets or packing. Frasier suction #10 or small disposable
suction tips are used to remove clots and blood from the
nasal cavity before treatment. Yankauer suction and an
emesis basin can be used to capture expectorated clots.
TREATING ANTERIOR EPISTAXIS
Epistaxis treatment is based on the site and degree of
bleeding. Failure to control an anterior bleed may indicate
the presence of a posterior bleed.
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Managing epistaxis

Compression is recommended initially for a simple

anterior septal nosebleed. Have the patient watch a clock
or set a timer while holding the fleshy part of the nose
for 10 minutes without releasing. If this method fails, the
patient will require medical evaluation by a primary care
provider, ENT specialist, or in an urgent or emergency
care setting.
Inspect for bleeding in the Kiesselbach plexus. A locally
applied vasoconstrictor can assist visualization and control
of bleeding. Oxymetazoline, the active ingredient in several
nasal decongestant sprays, is available and easy to use.
Suction or have the patient gently blow the nose, then
either spray or place a cotton pledget soaked with oxymetazoline in the nares. A pledget can be made using a
large cotton ball and unrolling it to about 4 in long. The
pledget is best placed using bayonet forceps to insure proper
placement along the nasal septum. Let the pledget remain
in place with gentle compression for 5 to 10 minutes. After
removing the pledget, examine the nares with a headlight
and nasal speculum.
Chemical cautery may be considered for persistent
oozing of an identifiable anterior site. Anesthetize the
patients nasal cavity with a pledget soaked with 2%
lidocaine (with or without epinephrine) for about 10
minutes. Remove the pledget and hold a silver nitrate
applicator on the site of bleeding and surrounding area
for no longer than 10 seconds. The mucosa will turn
whitish gray. Holding the cautery stick on an area for
more than 10 seconds poses the risk of septal perforation.
Use caution in cauterizing both sides of the septum in the
same session, as this may also cause tissue necrosis and
possible septal perforation.
Nasal packing is available for anterior and posterior
bleeding. For a simple anterior nasal bleed that has failed
compression and/or cautery, use a nasal tampon, balloon,
or a thrombogenic agent. Occasionally, both sides of the
nares may require packing either due to bilateral bleeding
or to achieve enough compression to control the bleed.
Bilateral packing is necessary for patients with septal
perforation.
Nasal tampons are made of a synthetic open-cell polymer. Although these polyvinyl alcohol sponges are rigid,
they are easy to use and effective. Anesthetize the patients
nare as described above. Coat the nasal tampon with
antibiotic ointment to act as a lubricant as well as to
prevent infection. Slide the nasal tampon directly along
the floor of the nasal cavity until the entire tampon is in
the nasal cavity. Then expand the tampon by infusing
about 10 mL of saline or sterile water with an angiocatheter or needle onto the anterior nasal tampon to soak the
material.
Nasal balloon catheters come in different types, including a low-pressure balloon encased in a carboxymethylated
cellulose (CMC) mesh. The mesh promotes thrombosis
once it contacts blood. These balloon catheters are conJAAPA Journal of the American Academy of Physician Assistants

TABLE 2.

Contents of an epistaxis kit

Head lamp
Nasal speculum
Bayonet forceps
Frasier suction #10
Suction setup
Emesis basin
Oxymetazoline
Lidocaine 2% with or without epinephrine
Cotton pledgets or balls/strips
Tongue blades
Eye protection
Nonsterile gloves
Silver nitrate sticks
Antibiotic ointment
Empty 10-mL syringes
Sterile water
Anterior packing (polyvinyl alcohol sponge or lowpressure balloon)
Posterior packing (dual balloon catheter or petroleumimpregnated gauze)
Hemostatic agents of choice

sidered less traumatizing to the nose than traditional nasal

tampons. They vary in length to allow compression from
the anterior to more posterior bleeding sites. CMC balloons are moistened with sterile water before insertion,
and are easy to insert in the nares in the office setting.
Remove the hard outer cover, moisten the pack with
sterile water, and immediately slide the pack along the
floor of the nose until it is completely inserted. (None of
the pack should be sticking out of the patients nose.) Then
inflate with air until the pilot cuff is firm. Tape the cuff to
the patients cheek.
Gauze packing with petroleum-impregnated ribbon gauze
can be used to control epistaxis. The packing is placed
with a bayonet forcep. Grasp the gauze and place it as far
back in the nasal cavity as possible, then grasp the next
segment of gauze and tightly layer each segment into the
nare. This requires a greater skill in placement and may
be deferred to an ENT specialist.
Thrombogenic agents are newer options to promote
clot formation and stabilize epistaxis. Forms include
surgical absorbable gauze, topical thrombin gel, and fibrin
glue. The medicated gauze and topical applications conform to irregular and wet mucosal surfaces. Medicated
gauze can be placed after cautery in patients at high risk
for recurrent bleeding. Studies indicate that thrombogenic
agents have a lower rebleeding rate and effectively control
epistaxis.3,4 Patients have less nasal pressure and find these
interventions more comfortable than traditional nasal
packing or balloons. Because this form of treatment is
absorbable, it does not have to be removed. This prevents
clots from being dislodged or the nasal mucosa from
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37

CME

being further irritated, as can occur during removal of

traditional packing.
Thrombogenic agents need to be applied directly to the
area of bleeding and compression may still be required
initially. When evaluating bleeding, remember that these
agents may take several minutes to work.
TREATING POSTERIOR EPISTAXIS
Because visualization and access to the bleeding site is
difficult, posterior epistaxis is challenging to treat. The
nares can be packed with petroleum-impregnated gauze
or a posterior balloon can be placed. A dual balloon
catheter is inserted along the floor of the nose until the
retention ring is at the nasal entrance. The posterior bal-

Surgical treatment is reserved

for ongoing hemorrhage that
fails conservative interventions.
loon is inflated with 10 mL of sterile water and the catheter is gently pulled forward until it lodges against the
nasopharynx. The anterior balloon is then inflated with
up to 30 mL of sterile water to hold the catheter in place.
Pad or protect the nasal entrance from any pressure the
balloon may create in its placement.
Although not licensed for this use, an indwelling urinary
catheter works well if a balloon catheter is not available.
Insert a 10-to-14 French catheter into the nasal cavity until
the indwelling urinary catheter is visible in the oropharynx.
Then slowly inflate the balloon with 10 mL of sterile water
and gently withdraw the catheter until compression occurs
on the posterior nasopharynx. While maintaining pressure
on the posterior nasopharynx (pulling the catheter toward
yourself), place a small C-clamp or umbilical clamp at the
anterior nares to hold the catheter. Ribbon gauze or packing may be placed around the catheter inside the nares for
added compression and control of bleeding. Apply a gauze
dressing to protect the external nares from the clamp and
pressure necrosis.
AFTER PACKING TREATMENT
After the nasal cavity has been treated or packed, always
use a light source and tongue blade to evaluate the
oropharynx to check for posterior bleeding. Epistaxis
that persists after packing is placed requires immediate
referral to an ED. Packing that results in good control
should remain in place for 3 to 5 days. Although experts
have debated whether to prescribe prophylactic oral
antibiotics to prevent toxic shock syndrome and sinusitis while the packing is in place, most ENT surgeons
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prefer prophylaxis.5 Simple anterior packing on one side

can be treated as an outpatient procedure, with referral to
an ENT specialist for follow-up in 3 to 5 days.
Patients who require bilateral packing or posterior
packing will need hospital admission and monitoring.
The potential risk of hypotension and bradycardia caused
by a nasovagal reflex is rare. This nasopulmonary
reflex was thought to occur during posterior nasal
packing or instrumentation but studies have demonstrated no change in pulmonary or cardiac function in
relation to posterior nasal packing.6 Patients are at possible risk of short-term sleep apnea due to the decreased
nasal air entry from the packing.1,4 The risk of displacement of the packing and possible recurrent bleeding
warrants ICU admission or a high level of monitoring.
A hospitalized patient will benefit from a humidified
face tent to provide moisture and comfort; the nasal
packing forces patients to breathe through the mouth
while sleeping.
UNCONTROLLED EPISTAXIS
Angiography with embolization was first performed for
epistaxis in 1972.2 Since then, it has become a common
alternative for uncontrolled epistaxis in medical centers
where it is available. Patients usually require anesthesia
and must tolerate IV contrast for this procedure.
Studying endovascular treatment for intractable epistaxis
in 30 patients, Vitek found a success rate of 87% after
embolization of the internal maxillary artery and a 97%
success rate after embolization of the internal and facial
arteries, with a 3% to 4% complication rate.7 Failure of
embolization treatment of epistaxis is often related to
continued bleeding from the ethmoidal branches of the
ophthalmic artery. Embolization of these branches is
contraindicated because ophthalmic artery embolization
carries a high risk of blindness and stroke.
Surgical treatment is reserved for ongoing hemorrhage
that fails conservative interventions. Surgery is performed
in the OR under general anesthesia; rigid endoscopy
is used to identify the site of bleeding. Surgical ligation
or cautery of the sphenopalatine artery is attempted
initially. Studies of posterior endoscopic cauterization
report success rates of 80% to 90%.2 If the site of bleeding is found from the ethmoidal region, a ligation of the
ethmoid artery is completed. This may require an external incision through the medial orbital wall just below
the eyebrow. Traditional or absorbable nasal packing
may be placed in the nasal cavity postprocedure as a
precaution.
ANTICOAGULATION AND HYPERTENSION
Managing epistaxis in patients taking anticoagulants is
challenging. Much debate and little consensus exist as to
whether anticoagulation should be continued, held,
or reversed when patients develop epistaxis.3 Medically
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Managing epistaxis

evaluate each patient to determine the risks of stopping

anticoagulation.
The role of hypertension in the initial onset of epistaxis
is controversial.8,9 Studies have demonstrated that patients
with epistaxis presenting to the ED have higher BP on
admission than controls. These patients also have a higher
incidence of previous nosebleeds.9 Patients with epistaxis
and uncontrolled BP can have persistent bleeding that is
difficult to control, so medical management of hypertension is vital. The hypothesis that elevated BP was secondary to anxiety during epistaxis also was studied. This
prospective comparative study looked at administering

Moisture is the key to

prevention. Patients with nasal
dryness should use saline
nasal spray.
diazepam to patients with epistaxis, increased BP, and
anxiety. The researchers found that diazepam did not
reduce anxiety or BP during acute epistaxis and was not
recommended.10 Therefore, evidence supports that hypertension itself must be controlled in a patient with acute
epistaxis and should be monitored closely.
FOLLOW-UP AND PREVENTION
All patients with a history of severe or recurrent epistaxis
should have an ENT evaluation. Provide patients with
written instructions for nasal care after epistaxis:
Patients should not blow their noses for 7 to 10 days
after the nosebleed. Patients should use saline nasal spray
several times a day and sniff gently instead of blowing
the nose.
Patients should apply petroleum or antibiotic ointment
in the nares twice a day.
Patients should avoid bending and lifting heavy objects.
Advise patients to open their mouths when sneezing.
Patients should use home humidifiers and bedside
vaporizers.
Tell patients to keep fingernails trimmed and avoid nose
picking.
For patients on supplemental oxygen, a humidified face
tent or mask is recommended. Limit the use of a nasal
cannula to during meals. Patients also should trim the
prongs of the tubing that enter the nose to prevent excessive dryness on the septum.
Moisture is the key to prevention. All patients on anticoagulation or antiplatelet medications (including NSAIDs)
should use nasal care. Patients with nasal dryness or a
JAAPA Journal of the American Academy of Physician Assistants

history of nosebleeds should add nasal care to their daily

regime.
Most nosebleeds are cyclic. A patient may have an
idiopathic nosebleed that stops as a clot is formed over
the bleeding site. If the patients nose becomes dry or is
blown and the clot becomes dislodged too soon, the nose
bleeds again. Until the mucosa underlying the clot is
allowed to heal, a patient may continue to have serial
bleeds. Moisture and prohibiting nose-blowing stops this
cycle and lets the nasal lining heal. Teaching patients how
to correctly try to control a nosebleed and perform proper
nasal care after a nosebleed may prevent an unnecessary
trip to a clinic or ED.
CONCLUSION
Epistaxis is a common medical event. Newer treatment
options are available and friendlier for healthcare providers and patients. Creating an epistaxis kit with all necessary
instruments and supplies can help clinicians treat patients
in an organized, stepwise fashion with confidence. Provide
patients with written instructions about treating nosebleeds
and reducing recurrences. Encourage patients on anticoagulation or oxygen to perform nasal care on a daily basis
to prevent epistaxis. JAAPA
Earn Category I CME Credit by reading both CME articles in this issue,
reviewing the post-test, then taking the online test at http://cme.aapa.
org. Successful completion is defined as a cumulative score of at
least 70% correct. This material has been reviewed and is approved
for 1 hour of clinical Category I (Preapproved) CME credit by the
AAPA. The term of approval is for 1 year from the publication date of
November 2014.

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anticoagulant therapy. Rhinology. 2004;42(2):92-97.
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trial of gelatin-thrombin matrix as first line treatment of
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nasopulmonary reflex. Laryngoscope. 1981;91(2):279-284.
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presentation is associated with arterial hypertension. Am J
Emerg Med. 2002;20(2):92-95.
9. Herkner H, Laggner AN, Mllner M, et al. Hypertension in
patients presenting with epistaxis. Ann Emerg Med. 2000;35(2):
126-130.
10. Thong JF, Lo S, Houghton R, Moore-Gillon V. A prospective
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blood pressure and anxiety levels in patients with acute
epistaxis. J Laryngol Otol. 2007;121(2):124-129.
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