Up to 60% of the general population experiences epistaxis in their lifetime. Epistaxis can be classified as anterior or posterior depending on the bleeding source. Anterior bleeds are more common and often self-limiting, while posterior bleeds can cause significant hemorrhage and require prompt medical attention. Treatment involves identifying the bleeding site, applying pressure, cauterization or nasal packing to achieve hemostasis. Persistent or severe bleeding may require hospitalization, endoscopic surgery, or angiographic embolization.

1. EPISTAXIS
BY: DR. TAYEB THOBAB , FAMILY MEDICINE SPECIALIST.
DR. TAHER KARIRI , FAMILY MEDICINE SPECIALIST.

2. OBJECTIVES
• Epidemiology
• Anatomy
• Etiology
• Approach and Management.

3. EPIDEMIOLOGY
• Up to 60% of the general population.
• only 10% or fewer seek medical attention.
• Bimodal age distribution, before age 10 or between 45 and 65 years of age.
• Seasonal variation, with predominance in winter months.

4. ANATOMY

5. ANATOMY
• Epistaxis may be classified as anterior or posterior, depending upon the source
of bleeding.

6. ANATOMY
• Anterior bleeds — the most common.
• A large proportion is self-limited and can be
managed definitively in the primary care
setting.
• Up to 90% occur within Kiesselbach's plexus.

7. • Posterior bleeds:
• Can result in significant hemorrhage.
• Most patients require prompt referral to an
emergency department.

8. COMMON CAUSES OF EPISTAXIS
LOCAL CAUSES
• Epistaxis digitorum (nose picking)
• Trauma
• Dryness
• Chronic sinusitis, Rhinitis
• Foreign bodies
• Irritants (e.g., cigarette smoke)
• Medications (e.g., topical
corticosteroids)
• Septal deviation, perforation
• Vascular malformation or
telangiectasia
• Intranasal neoplasm or polyps
• Aneurysm of the carotid artery.

9. COMMON CAUSES OF EPISTAXIS
SYSTEMIC CAUSES
• Hypertension
• Liver disease (e.g., cirrhosis)
• HIV
• Medications (e.g., aspirin, warfarin,
NSAID)
• Alcohol
• Hemophilia
• Platelet dysfunction
• Thrombocytopenia
• von Willebrand disease
• hereditary hemorrhagic telangiectasia
(OWR)
• Leukemia

10. EVALUATION
• Initial assessment:
• Should focus on ABC.
• Airway intervention, fluid resuscitation, and emergent otolaryngologic
consultation can be necessary in severe epistaxis.

11. INITIAL TAMPONADE
• Properly instructed patients may achieve hemostasis unassisted while the
evaluation gets underway. The following approach may be helpful:
Patient blows their nose to remove blood and clots.
Clinician sprays the nares with oxymetazoline.
Patient pinches the alae tightly against the septum and holds continuously for 10
minutes.

13. HISTORY
• Interduce yourself
• Establish rapport
• C/O: duration, site, onset, timing, severity, previous episodes.
• Any trauma, exposure to extreme weather or altitude changes.
• Any ongoing problems: rhinitis, sinusitis, hypertension, bleeding disorder, liver
disease.
• Any medications: nasal steroids, aspirin, warfarin, clopidogrel.

14. HISTORY
• ICEE
• Family and social history:
bleeding disorders, abuse or domestic violence, smoking, cocaine, alcohol

15. PHYSICAL EXAMINATION
• General examination
• vital signs, mental status, and airway of any patient with significant bleeding.
• looking for signs of airway compromise or hypovolemic shock.
• signs of coagulopathy (eg, ecchymoses, petechiae, telangiectatic lesions).

16. PHYSICAL EXAMINATION
Before examining the nose:
The nasal cavity should be anesthetized.
cotton swabs soaked in an anesthetic and vasoconstrictive agent e.g:
• 2% lidocaine, lidocaine with epinephrine.
• Oxymetazoline nasal preparation, can provide vasoconstriction.

17. EXAMINATION OF THE NOSE
• Head of an examination table to upright so the patient can sit
comfortably while head movement is restricted.
• Ask the patient to look directly ahead and attempt the sniffing position.
• Use nasal speculum. with good light.
• Clots may be cleared either with suction or by asking the patient to
gently blow his or her nose.

18. EXAMINATION OF THE NOSE
• Inspect the area of Kiesselbach's plexus first
• Look closely for bleeding, ulceration, or erosion.
• Also inspect the nasal vestibule, septum, and turbinates for sources of bleeding.
• If bleeding site cannot be identified. In such cases, bleeding may be from a
posterior source or minor injury that already resolved.

20. INVESTIGATIONS
• CBC
• PT, PTT, INR
• Coagulation factors.
• crossmatch should be obtained in the setting of massive or prolonged
hemorrhage.
• LFT if indicated

21. TREATMENT OF ANTERIOR BLEEDING

22. BLEEDING STOPS WITH CONSERVATIVE
MEASURES
• If no anterior source is evident and bleeding has stopped.
• It is reasonable to observe the patient for approximately 30 minutes for
recurrent bleeding. Such patients should be discharged with antibiotic ointment.
• The nose should be packed only if bleeding recurs rapidly.

23. CAUTERY
• If an anterior bleeding source is visualized, first-line treatment consists of chemical
or electrical cautery. After applying anesthetic.
• Chemical cautery is usually performed with silver nitrate sticks.
• Cautery is applied for a few seconds (no longer than 10 seconds), until a white
precipitate forms.
• antibiotic ointment with a fingertip or cotton swab three times daily for three days.

25. NASAL TAMPONS
• Nasal packing is most easily accomplished with a
nasal tampon.
• Coat the tampon with bacitracin ointment to
facilitate placement, and possibly decrease the risk
of toxic-shock syndrome.

26. GAUZE PACKING

27. NASAL BALLOON CATHETERS

28. THROMBOGENIC FOAMS AND GELS
• As effective as cautery and packing.
• caution in patients in whom the potential dangers of systemic thrombosis are
high
(eg, known coronary or cerebrovascular disease).

29. THROMBOGENIC FOAMS AND GELS
• Floseal.

30. THROMBOGENIC FOAMS AND GELS
• tranexamic acid (TXA).

31. THROMBOGENIC FOAMS AND GELS
• Gelfoam

32. THROMBOGENIC FOAMS AND GELS
• Surgicel

33. THROMBOGENIC FOAMS AND GELS
• Avitene.

34. PERSISTENT BLEEDING
• the contralateral naris may be packed, thereby providing a counterforce to
promote tamponade.
• If bilateral anterior packing fails to produce hemostasis, the odds of a posterior
source increase greatly.

35. ANTIBIOTICS AND TOXIC SHOCK SYNDROME
• 16 per 100,000 packings.
• Be alert for signs of toxic shock syndrome (fever, hypotension, desquamation, and mucosal
hyperemia).
• Abs should not be given routinely for prophylaxis.
• It may be reasonable to treat patients at greater risk of infection, such as those with diabetes,
advanced age, or immunosuppression.
• If prescribed, an antibiotic with staphylococcal coverage should be selected, such
as amoxicillin-clavulanate or a second-generation cephalosporin; topical mupirocin may also
be used.

36. FOLLOW-UP
• If vital signs and respiratory function remain normal after packing.
• the patient may be safely referred for specialist follow-up in 24 to 48 hours, with
advice to present to an emergency department sooner if bleeding recurs.

37. PREVENTION
• Sleep in a humidified environment.
• A topical antibacterial (eg, mupirocin) or bacteriostatic (eg, bacitracin) ointment
may be gently applied to the nasal mucosa with a cotton-tipped swab in an
attempt to prevent recurrence.
• Directing nasal medication sprays away from the septum may decrease the risk
of epistaxis.

38. TREATMENT OF POSTERIOR BLEEDING
• Prefer balloon catheters.
• If balloon catheters are not available, alternatives include a Foley catheter and
cotton packing.

40. COTTON PACKING

41. HOSPITALIZATION
• Most patients with a suspected posterior source of bleeding.
• Patients with anterior packing who cannot be reasonably expected to return for
prompt follow-up or who have serious comorbidities or concerning symptoms.
• Prolonged retention of nasal packing (greater than 72 hours) - necrosis, TSS,
sinus or nasolacrimal infections, and dislodgment.

42. COMPLICATIONS
• 3% complication rate, include:
• synechiae (intranasal adhesions)
• Aspiration
• angina,
• myocardial infarction
• hypovolemia.

43. TREATMENT FAILURES
• Surgical treatment is often performed endoscopically and can include ligation of
the sphenopalatine or anterior ethmoid artery.

44. • Angiographic embolization is increasingly common, The rate of severe
complications (eg, stroke, blindness) with embolization is approximately 4%.

46. THANK YOU
• Any questions?

47. REFRENCES