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Snapshot
  •  A 14-year-old boy with no significant past medical history presents to the ED after being struck in the nose during a basketball game. There is frank blood coming from the nares.
Introduction
  • Nosebleeding that can arise from either the anterior or posterior circulation
    • anterior nosebleeds
      • involves bleeding from Kiesselbach's plexus
      • seen most commonly in children/adolescents
      • most commonly caused by trauma including nose picking
    • posterior nosebleeds
      • involves bleeding from Woodruff's plexus
      • seen most commonly in older adults with hypertension
      • not incited by trauma
  • Less common causes of epistaxis
    • nasopharyngeal angiofibroma
      • recurrent nosebleeds or obstruction without a history of trauma or blood dyscrasia
    • leukemia
    • blood dyscrasia
      • ex) vWD, hemophilia
    • Osler-Weber-Rendu syndrome
    • cocaine or other intranasal drug use
    • any cause of thrombocytopenia
      • ex) ITP
    • foreign bodies (pediatrics)
      • associated with persistent symptoms and purulence 
Presentation
  • Symptoms
    • bleeding from the nose
Evaluation
  • Assess vital signs if bleed is signficant
  • Majority do not require testing other than direct visualization
  • Have patient sit up with body tilted forward to allow blood to be passed out of the nares instead of passing posteriorly into the pharynx
 
Treatment
  • In anterior epistaxis, the following treatment protocol is required
    • compression
    • topical vasoconstriction
      • phenylephrine
    • chemical/electrocautery
    • nasal packing
    • arterial ligation or embolization
  • In posterior epistaxis, the following treatment protocol is required
    • blood pressure reduction
    • posterior nasal packing
    • arterial ligation of embolization
Prognosis, Prevention, and Complications
  • Patient advice for future anterior bleeds
    • compress cartilagenous portion of nose for 10-15 without releasing
    • avoid tissue paper placement inside the nose or swallowing blood
    • prevent with proper nasal hygiene which includes moisturization and avoidance of digital placement in the nose
  • Patient advice for future posterior bleeds
    • good long-term hypertension control
    • avoid tissue paper placement inside the nose or swallowing blood
 

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