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Updated: Dec 17 2021


  • 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
    • 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
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