Epistaxis

1. THE 2-MINUTE PHYSIOLOGY (Rapid Pathophysiology)

• Anterior Epistaxis (90%): The vast majority of nosebleeds occur at Kiesselbach's plexus (Little's area) on the anterior septum. This is a highly vascular watershed area where the anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries anastomose. Bleeding here is typically driven by mucosal dryness, digital trauma, or localized inflammation, which easily disrupts the fragile capillary/arteriolar bed.
• Posterior Epistaxis (10%): Occurs at Woodruff's plexus (located posteriorly in the inferior meatus) and is primarily supplied by the sphenopalatine artery. Posterior bleeds are more frequently arterial, heavy, and typically seen in older patients with underlying arteriosclerosis, coagulopathy, or hypertension.

2. THE BEDSIDE ACTION PLAN (Rapid ER Management)

• Immediate Stabilization: Position the patient upright and leaning forward (the "sniffing position") to prevent aspiration and the swallowing of blood (which causes nausea and vomiting). Have the patient forcefully blow their nose once to clear out obstructing clots.
• First-Line (Compression & Constriction):
• Apply a topical vasoconstrictor (e.g., oxymetazoline 0.05% spray or epinephrine 1:10,000) often mixed with a topical anesthetic (e.g., lidocaine 4%). This can be sprayed via atomizer or applied on soaked cotton balls.
• Apply direct, continuous, firm pressure to the cartilaginous (lower) half of the nose for 10–15 minutes uninterrupted.
• Second-Line (Cautery): If a discrete bleeding vessel is visualized after clearing clots, perform chemical cautery with a Silver Nitrate stick. Roll the stick directly over the bleeding point for 5–10 seconds.
• Third-Line (Anterior Packing): If bleeding persists, insert an anterior nasal pack (e.g., Rapid Rhino or Merocel). Soak a Rapid Rhino in sterile water (not saline), insert it straight back along the floor of the nasal cavity, and inflate the balloon with air until the pilot cuff is firm.
• Fourth-Line (Posterior Packing): For intractable or posterior bleeds, place a posterior balloon device (e.g., Epistat dual-balloon) or a standard 10F–14F Foley catheter, and inflate it in the nasopharynx to tamponade the sphenopalatine artery.

3. THE DIAGNOSTIC GRID (Differential Diagnosis & Workup)

• "Can't-Miss" Differential Diagnoses:
• Upper Gastrointestinal Bleeding (UGIB): Massive epistaxis swallowed into the stomach can mimic hematemesis from a primary UGIB. Differentiating the source is critical for the correct resuscitation pathway.
• Basilar Skull Fracture: Trauma patients with epistaxis may have a cribriform plate fracture; blind nasal packing or NG tube insertion is absolutely contraindicated.
• Severe Coagulopathy: Suspect in patients on anticoagulants (warfarin, DOACs) or with advanced liver disease.
• Prioritized Diagnostic Workup:
• Routine labs are generally unnecessary for standard anterior epistaxis.
• CBC and Type & Screen: Indicated for massive, prolonged bleeds, or in patients exhibiting signs of hemodynamic instability.
• PT/INR & PTT: Indicated only for patients actively taking anticoagulants or with a known history of bleeding diatheses/cirrhosis.

4. THE VISUAL BOARD (ECG / POCUS / Imaging)

• The Equipment Setup: The most critical "visual" aspect of epistaxis management is proper illumination and clearing of the field. You must use a headlamp, a nasal speculum, and Frazier suction.
• Visualizing the Source:
• Anterior: Look directly at the anterior septum (Kiesselbach's plexus) for an active, bright red arterial spurt or a raw, oozing mucosal defect.
• Posterior: If the anterior septum is clear but there is brisk, continuous bleeding down the posterior pharynx, a posterior source is highly likely.
• Imaging: Routine imaging is not indicated. Obtain a non-contrast Maxillofacial CT only if facial trauma or a bony fracture is suspected.

5. THE SCORING MATRIX (Risk Stratification & Guidelines)

• Disposition Criteria based on Intervention:
• Discharge: Patients whose bleeding stops with pressure, cautery, or an anterior pack. (Patients discharged with anterior packs require prompt ENT follow-up in 48-72 hours for removal).
• Admission: Any patient requiring posterior packing must be admitted, often to a step-down unit or ICU. Posterior packs carry a risk of vagal stimulation leading to bradycardia, hypoxia, and airway compromise.
• Anticoagulation Reversal: Follow standard hematologic guidelines (e.g., giving Prothrombin Complex Concentrate [PCC] for life-threatening, uncontrollable epistaxis in a patient on a DOAC or with a supratherapeutic INR on warfarin).

6. THE DANGER ZONE (Pitfalls & Critical Actions)

• Cognitive Trap (Bilateral Cautery): Never use silver nitrate to cauterize both sides of the nasal septum simultaneously. This disrupts the blood supply to the septal cartilage and will cause a permanent septal perforation.
• Cognitive Trap (Angling Upward): When placing an anterior pack (like a Rapid Rhino), inserting it upward toward the eyes is a common trainee mistake. Critical Action: The pack must be inserted straight back, parallel to the palate/floor of the nasal cavity.
• Critical Action (Airway Protection): In massive epistaxis (often posterior), the patient can rapidly aspirate or asphyxiate on their own blood. Be prepared for early, challenging rapid sequence intubation (RSI) using video laryngoscopy and aggressive suctioning (e.g., using a meconium aspirator or large-bore suction catheter).

7. MCQ MASTERCLASS (Written Exam Tips)

• Buzzwords:
• "Kiesselbach's plexus" = Anterior epistaxis (most common).
• "Sphenopalatine artery" or "Woodruff's plexus" = Posterior epistaxis.
• "Cribriform plate fracture" or "Raccoon eyes" = Contraindication to nasal packing.
• Classic Distractor: A question describes an uncomplicated anterior nosebleed that stops with pressure and asks for the next best step. Options will include "order an INR" or "obtain a CBC." Correction: Uncomplicated, easily controlled epistaxis in a patient without a bleeding history requires no laboratory workup.

8. THE BOARDROOM SCRIPT (OSCE & Oral Board Tips)

• The Initial Approach: "I will place the patient in an upright, sniffing position and instruct them to blow their nose to clear all clots. I will then have the patient hold firm, continuous pressure on the cartilaginous aspect of the nose while I don my headlamp, set up Frazier suction, and prepare topical oxymetazoline and lidocaine."
• The Escalation Script: "Despite 15 minutes of direct pressure and topical vasoconstrictors, the patient continues to bleed actively. Upon inspection with a nasal speculum, I cannot visualize an anterior source, and there is brisk bleeding down the posterior pharynx. I am highly concerned for a posterior bleed. I will immediately place a dual-balloon posterior catheter, inflate it to achieve tamponade, secure the airway if there is any sign of compromise, and consult ENT for urgent admission and operative management."