Snapshot A 8-year-old boy presents to the pediatric emergency department for a nose bleed. His symptoms began after he was hit in the face with a basketball. He denies any shortness of breath, hemoptysis, or hematemesis. Family history is unremarkable. On physical examination, there is small volume bleeding. He is asked to bend at the waist and press on his nasal alae. Hemostasis is eventually achieved. Introduction Overview acute bleeding from the nasopharynx or the nose Associated conditions nasal trauma Epidemiology Demographics occurs in children or in the elderly (most common) Risk factors digital trauma to the nose (most common) nasal mucosal drying (e.g., dry air) rhinitis septal deviation coagulopathy medications (e.g., antiplatelet and anticoagulant therapy) foreign body ETIOLOGY Pathophysiology anterior nose bleed damage to Kiesselbach plexus which results in bleeding posterior nose bleed damage to the posterolateral branches of sphenopalatine artery can be severe and life-threatening Presentation Symptoms bleeding from the nose anterior nose bleed small volume bleed posterior nose bleed large volume bleed Studies Nasal endoscopy Serum studies in cases of severe bleeding complete blood count type and screen PT/INR and aPTT Differential Hemoptysis differentiating factors blood with coughing signs of respiratory distress Hematemesis differentiating factors bloody emesis history of gastrointestinal illness (e.g., peptic ulcer disease) melena Malignancy/mass juvenile angiofibroma assess with CT/MRI Treatment Conservative and lifestyle squeeze alae and bend at the waist indication initial management in anterior nose bleeds anterior nasal packing indication performed in patients with presumed anterior nose bleeds when cautery fails posterior nasal packing indication performed when hemostasis is not achieved with anterior nose packing increases the suspicion for posterior nose bleeds Medical and pharmacologic oxymetazoline indication initial management in anterior nose bleeds Surgical and interventional cautery indication performed when an anterior nose bleed is identified via rhinoscopy and conservative measures and oxymetazoline is unsuccessful modality chemical (e.g., silver nitrate) electrical endoscopic ligation or embolization indication performed after hemostasis is not achieved with posterior nasal packing Complications Hypovolemia Angina and myocardial infarction Prognosis Most nosebleeds are benign and self-limiting Most cases of anterior epistaxis are responsive to local treatment