Introduction
Most nosebleeds arise from little’s area on the nasal septum. Five arteries anastomose to form little’s area:
- Anterior Ethmoid Artery
- Posterior Ethmoid Artery
- Sphenopalatine Artery
- Great Palatine Artery
- Superior Labial Artery
Causes
Local
- Idiopathic
- Trauma – nose picking, nasal fracture
- Drug Induced – Nasal sprays, anticoagulants
- Foreign Body
- Rhinitis
Systemic
- Clotting disorders
- Hypertension
- Vasculitis (e.g Wegener’s Granulomatosis)
- Hereditary Haemorrhagic Telangiectasia (a.k.a Osler-Weber-Rendu disease, an autosomal dominant condition causing oral telangiectasia and epistaxis)
Management
- Airway, Breathing, Circulation!
- Gain IV access with a large bore cannula
- Send bloods for FBC, Group & Save and a clotting screen
- Give IV fluids
- Get the patient to sit upright, lean forwards and pinch the soft part of the nose
- Advise the patient to spit out any blood in the mouth
- Monitor pulse and blood pressure for signs of hypovolaemic shock
- If a bleeding vessel is visible consider cautery with silver nitrate
- Failing this pack the nose with Merocel nasal packs
- If examination suggests a posterior haemorrhage (i.e from the sphenopalatine artery) then try a balloon catheter to compress the bleeding vessel
- If this fails to stop the bleeding then the patient may need surgical ligation of the sphenopalatine artery