Nose bleed

Epistaxis is one of the commonest presentations at the accident and emergency (A&E) department and is the most common ENT emergency (1). Most cases of nose bleeds are minor or self limiting but rarely can be a life threatening emergency due to massive bleeding (1,2).

An estimated 60 % of the general population has had at least one episode of epistaxis throughout their life time (2).

• out of these only 6% sought medical assistance for it
• 1.6 in 10,000 required hospitalisation (3)
• a bimodal distribution is seen in the poulation
  • the incidence peaks at ages less than 10 years and above 50
  • in the young, the blood comes from Little's area, a highly vascular area at the anterior border of the nasal septum. With age the site of bleeding moves posteriorly (2)
• rare in children under the age of 2 years and if present is often associated with injury or serious illness (4)
• seasonal variation can also be seen with an increase during the winter months (4)
• occurs frequently in males than in females (2)

Epistaxis may be due to local causes or general causes.

Epistaxis is usually classified into two types:

• anterior bleeding
• posterior bleeding (2)

Epistaxis summary (5)

• epistaxis is common
  • an estimated lifetime prevalence in the United States of 60%
  • approximately 6% of persons who have nosebleeds seek medical attention.
• management of epistaxis is straightforward in most cases but can be challenging in patients with cardiovascular disease, impaired coagulation, or platelet dysfunction.
• epistaxis is appropriately controlled in a systematic and escalating fashion
  • initial management
    • patients in the medical setting are advised to apply digital compression to the lower third of the nose for 15 to 20 minutes, which is followed by anterior rhinoscopy
• anterior bleeding can usually be controlled with topical vasoconstrictors, tranexamic acid, cautery, or anterior nasal packing
  • intranasal tranexamic acid
    • study evidence found addition of intranasal tranexamic acid to controlled topical therapy of phenylephrine and lidocaine was linked to a lower rate of need for anterior nasal packing, stay in A+E for >2hrs, and rebleeding in 24hrs (6)
• continued epistaxis despite these measures requires more aggressive treatment, with the involvement of specialists in otolaryngology and head and neck surgery and, generally, hospital admission

Reference:

• (1) Tikka T. The Aetiology and Management of Epistaxis. Otolaryngology Online Journal (2016) Volume 6, Issue 2
• (2) Kucik CJ. Management of epistaxis. American Family Physician 2005; 71(2)
• (3) Upile T, et al. A change in UK epistaxis management. Eur Arch Otorhinolaryngol. 2008;265(11):1349-54
• (4) McIntosh N, Mok JY, Margerison A. Epidemiology of oronasal hemorrhage in the first 2 years of life: implications for child protection. Pediatrics. 2007;120(5):1074-8
• (5) Seikaly H. Epistaxis. N Engl J Med 2021; 384:944-951
• (6) Hosseinialhashemi M et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022 Jun 22:S0196-0644(22)00247-5.