Makindo Medical Notes

💡 The nasal blood supply lies very superficially, designed to humidify & warm inspired air — but at the cost of vulnerability to bleeding. ⚠️ Never underestimate epistaxis: patients can lose significant volumes (including occult blood if swallowed).

📖 About

• Epistaxis = bleeding from nasal mucosal vessels.
• Usually mild/self-limiting, but occasionally life-threatening.
• Blood may be swallowed → occult loss; always assess haemodynamic compromise (tachycardia, postural hypotension).

🧠 Anatomy

• ~90% arise from Kiesselbach’s plexus (Little’s area, anterior).
• Posterior bleeds = Woodruff’s plexus / sphenopalatine artery → severe, elderly, harder to control.

🩸 Risk Factors

• Hypertension, bleeding disorders, anticoagulants.
• Nasal trauma, nose-picking, recent URTI.
• Cocaine use, alcohol excess.
• Atherosclerosis, raised venous pressure (mitral stenosis).
• Haematological disease: thrombocytopenia, leukaemia, haemophilia.

🩺 Clinical Assessment

• History: duration, volume, triggers, family bleeding history.
• Drugs: warfarin, aspirin, clopidogrel, NSAIDs.
• Exam: anterior vs posterior, ENT look for masses/trauma.

🔎 Investigations

• FBC, U&E, clotting screen if coagulopathy suspected.
• Group & Save / X-match if severe bleeding.

⚠️ Complications

• Hypovolaemia, anaemia, shock.
• Packing complications (pressure necrosis, infection).

🛠️ Management

• Resus (ABC): IV access, monitoring, fluids/blood if needed.
• First aid: Sit forward, pinch soft part of nose 10–15 mins, spit blood out (avoid swallowing).
• Topical: Clear clot, apply pledget with lidocaine + adrenaline.
• Cautery: Silver nitrate if visible anterior point (⚠️ only one side to avoid septal perforation).
• Packing: Merocel® / RapidRhino® if cautery fails or posterior bleed suspected → admit ENT.
• Posterior bleeds: Balloon/Foley catheter pack, antibiotics cover, ENT admission.
• Post-bleed advice: Avoid nose-blowing, hot drinks, alcohol, heavy lifting x 24 hrs.

🩺 Nasal Cautery Tips

• Clear clots, apply topical anaesthetic + vasoconstrictor.
• Identify bleeding point (red dot) → touch with silver nitrate 3–10 sec until grey-white.
• Apply Naseptin® cream after cautery.

👶 Children

• Most bleeds are anterior and minor, often from nose-picking or URTI crusting.
• Encourage simple first aid (pinch nose, lean forward).
• Cautery may be difficult; consider referral if recurrent or severe.
• Check for bleeding disorders (esp. if frequent/refractory).
• Reassure parents: most are self-limiting; use emollients (Vaseline) to keep mucosa moist.

🧓 Elderly

• More likely to have posterior bleeds (harder to control, greater blood loss).
• Often on anticoagulants or antiplatelets → check INR/medication history.
• Higher risk of hypovolaemia, anaemia, aspiration → admit if frail or recurrent.
• Consider hypertension and atherosclerosis as contributory factors.
• Posterior packing/IR embolisation may be required more frequently than in younger patients.

📌 Exam Pearls

• Anterior bleed → Little’s area (easy to compress). Posterior bleed → profuse, elderly, more serious.
• Always check anticoagulant history.
• Do not cauterise both septal sides (risk perforation).
• Persistent/recurrent epistaxis → exclude hypertension, coagulopathy, or tumour (esp. JNA in young males).

📖 References

• NICE CKS – Epistaxis