Applied Evidence

Epistaxis: A guide to assessment and management

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References

Numerous causes: From trauma to medications

Epistaxis can be caused by local, systemic, or environmental factors; medications; or be idiopathic in nature (TABLE 12). It commonly arises due to self-inflicted trauma from nose picking, particularly in children; trauma to nasal bones or septum; and mucosal irritation from topical nasal drugs, such as corticosteroids and antihistamines. Other local factors include septal abnormalities, such as septal perforation, inflammatory diseases, rhinosinusitis, illicit drug use (eg cocaine), iatrogenic causes, and neoplasia.

Etiology of epistaxis

Red flags for neoplasia include unilateral or asymmetric symptoms, such as nasal blockage, facial pain, rhinorrhea, headaches, facial swelling or deformity, and cranial neuropathies (ie, facial numbness or double vision). Other red flags include Southeast Asian origin (nasopharyngeal carcinoma), loose maxillary teeth, and deep otalgia (TABLE 22). In adolescent males, it is important to consider juvenile nasopharyngeal angiofibroma, a benign tumor that can bleed extensively.

Red flags for neoplasia

Systemic factors include age, hypertension, alcohol use, acquired coagulopathies due to liver or renal disease, hematologic abnormalities, circadian rhythms, and genetic disorders such as hereditary hemorrhagic telangiectasia (HHT), hemophilia, and von Willebrand’s disease.2

Medications that contribute to epistaxis include antiplatelet agents, such as aspirin and clopidogrel; nonsteroidal anti-inflammatory drugs (NSAIDs); warfarin and novel oral anticoagulants (NOACs); and complementary and alternative medicines, such garlic, gingko, and ginseng. Environmental factors include temperature and humidity.2

Ask about trauma, but also about upper GI hemorrhage

Resuscitation and control of bleeding (which we’ll discuss in a moment) should always take priority. A thorough history and examination are also essential. It’s important to elicit details of the acute episode and any previous episodes, including the duration, severity, frequency, laterality of bleed, and contributing or inciting factors.1,2 Posterior epistaxis often occurs from both nostrils and feels as though blood is dripping down the throat rather than the nose.

Continue to: Hematemesis and melena from upper gastrointestinal hemorrhage...

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