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| '''Editor in Chief''': [[User:Ludi|Liudvikas Jagminas, M.D., FACEP]] [mailto:LJagminas@mhri.org] Phone: 401-729-2419 | | '''Editor in Chief''': [[User:Ludi|Liudvikas Jagminas, M.D., FACEP]] [mailto:LJagminas@mhri.org] Phone: 401-729-2419 |
| ==Overview== | | ==[[Epistaxis overview|Overview]]== |
| An '''epistaxis''' is the relatively common occurrence of [[hemorrhage]] (bleeding) from the [[nose]], usually noticed when it drains out through the [[nostril]]s. There are two types: anterior (the most common), and posterior (less common, and more severe). Sometimes in more severe cases, the blood can come up the [[nasolacrimal duct]] and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause [[nausea]] and vomiting. It only accounts for .001% of all deaths in the U.S.
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| ==Etiology== | | ==[[Epistaxis historical perspective|Historical Perspective]]== |
| The cause of nosebleeds can generally be divided into two categories, ''[[local]]'' and ''[[:wikt:systemic|systemic]]'' factors.
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| === Local factors === | | ==[[Epistaxis pathophysiology|Pathophysiology]]== |
| * Anatomical deformities, such as septal spurs or [[Hereditary hemorrhagic telangiectasia|Osler-Weber-Rendu Syndrome]]
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| * [[Inhalant|Chemical inhalant]]
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| * Inflammatory reaction (eg. acute respiratory tract infections, chronic sinusitis, allergic rhinitis and environmental irritants)
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| * [[Foreign body|Foreign bodies]]
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| * Intranasal tumors ([[Nasopharyngeal carcinoma]] in adult, and [[nasopharyngeal angiofibroma]] in adolescent males)
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| * Nasal prong O<sub>2</sub> which tends to dry the nasal mucosa
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| * Nasal sprays, particularly prolonged or improper use of nasal steroids
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| * Surgery (such as septoplasty and endoscopic sinus surgery)
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| * [[Physical trauma|Trauma]] (usually a sharp blow to the face)
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| * [[Nose-picking]]
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| * Low relative humidity of air breathed occurring especially during winter seasons.
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| ===Systemic factors=== | | ==[[Epistaxis causes|Causes]]== |
| * Drugs - [[Aspirin]], [[Fexofenadine]]/[[Allegra]]/[[Telfast]], [[warfarin]], [[ibuprofen]], [[clopidogrel]], [[isotretinoin]], desmopressin and others
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| * [[Alcohol intoxication|Alcohol]] (due to [[vasodilation]])
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| * [[Allergies]]
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| * [[Dyscrasia|Blood dyscrasias]]
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| * [[Heart failure]] (due to an increase in [[blood pressure#Venous pressure|venous pressure]])
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| * [[Hematological malignancy]]
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| * [[Hypertension]]
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| * [[Infectious diseases]]
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| * [[Malnutrition]] (especially [[anemia]])
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| * [[Narcotics]]
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| * Vascular disorders
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| * [[Nose-picking]] (especially in children)
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| * Muscle tightness as caused by [[scoliosis]] (the tightened muscles cause blood vessels to become constricted, resulting in nosebleeds from the same side as the tightened muscles).
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| == Complete Differential Diagnosis of Epistaxis==
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| In alphabetical order. <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
| | ==[[Epistaxis differential diagnosis|Differentiating Asherman's syndrome from other Diseases]]== |
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| * [[Alcoholism]]
| | ==[[Epistaxis epidemiology and demographics|Epidemiology and Demographics]]== |
| * [[Allergic Rhinitis]]
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| * [[Aortic isthmus stenosis]]
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| * [[Aplastic Anemia]]
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| * [[Arteriosclerosis]]
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| * [[Arteriovenous malformation]]
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| * Avitaminosis C
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| * Bleeding septal polyp
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| * [[Chronic hepatitis]]
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| * [[Cirrhosis]]
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| * [[Coagulopathy]]
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| * [[Coarctation of the aorta]]
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| * [[Disseminated Intravascular Coagulation]] ([[DIC]])
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| * [[Drugs]] such as [[aspirin]], [[clopidogrel]], [[coumadin]], [[heparin]], [[enoxaparin]], [[bivalirudin]], [[fondaparinux]], [[eptifibatide]], [[abciximab]], [[tirofiban]]
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| * Dry climate
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| * Dust
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| * [[Erythrocythemia]]
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| * External [[trauma]]
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| * Forceful nose blowing
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| * [[Hemophilia]]
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| * Hemorrhage of Kiesselbach's area
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| * [[Hypertension]]
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| * [[Infection]]
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| * [[Influenza]]
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| * Internal [[trauma]]
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| * Juvenile [[nasopharyngeal fibroma]]
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| * [[Leukemia]]
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| * [[Liver failure]]
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| * [[Malaria]]
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| * [[Measles]]
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| * [[Multiple Myeloma]]
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| * Nasal [[diphtheria]]
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| * Nasal foreign body
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| * Nasal [[fracture]]s
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| * [[Nasal polyp]]s
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| * Nasal [[syphilis]]
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| * [[Neoplasm]]
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| * Nose picking
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| * [[Osler's Disease]]
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| * Other [[trauma]] to the face
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| * [[Pancytopenia]]
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| * Postoperative
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| * [[Psittacocis]]
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| * Repeated [[cocaine]] use
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| * Rhinitis sicca
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| * [[Scarlet Fever]]
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| * [[Septal deviation]] or perforation
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| * Sinus [[fracture]]
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| * [[Sinusitis]]
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| * [[Snakebites]]
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| * [[Streptococcal]] infection
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| * [[Telangiectasias]]
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| * [[Thrombocytopathy]]
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| * [[Thrombocytopenia]]
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| * [[Typhoid Fever]]
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| * [[Uremia]]
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| * Vapors
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| * [[Vitamin K Deficiency]]
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| * [[Von Willebrand's Disease]]
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| * [[Waldenstrom's Macroglobulinemia]]
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| * [[Wegener's Granulomatosis]]
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| * [[Werlhof's Disease]]
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| * Winter months
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| == Diagnosis == | | ==[[Epistaxis risk factors|Risk Factors]]== |
| === History and Symptoms ===
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| * History of nasal irritation or trauma
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| * Allergy symptoms
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| * [[Rhinorrhea]]
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| * Bleeding in other areas
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| * Exposure
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| * Sinus/tooth pain
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| * Previous epistaxis
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| * Inciting factors
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| * Frequency
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| === Physical Examination ===
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| ==== Ear Nose and Throat (ENT) ====
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| * Evidence of setpal perforation
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| * Washing area may increase visibility
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| * Blood in mouth (without obvious nasal bleed) indicative of a posterior bleed
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| === Laboratory Findings ===
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| * [[Complete blood count]] ([[CBC]])
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| * [[Platelet count]]
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| * [[Prothrombin time]] ([[PT]])
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| * [[Partial thromboplastin time]] ([[PTT]])
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| ==== MRI and CT ====
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| * CT scan of nasal area and sinus may be indicated
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| ==== Other Diagnostic Studies ====
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| * [[Bone marrow]] [[biopsy]]
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| * [[Biopsy]] of suspicious areas
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| ==Pathophysiology== | | ==[[Epistaxis screening|Screening]]== |
| All nosebleeds are due to tears in the mucosal lining and the many small blood vessels it contains. Fragility or injury may cause the tears, while inflammation, coagulation problems and other disorders may make the injury harder to repair.
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| == Treatment == | | ==[[Epistaxis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ===Medical=== | | == Diagnosis == |
| The flow of blood normally stops when the blood [[coagulation|clots]], which may be encouraged by [[Emergency bleeding control|direct pressure]] applied by pinching the soft fleshy part of the nose. This applies pressure to [[Little's area]], the source of the majority of nose bleeds and promotes clotting. Pressure should be firm and be applied for at least 10 minutes while keeping the head in the neutral position and spitting out any blood which flows into the mouth. There is no benefit to pinching the bridge of the nose or to tilting the head backwards or forwards. Swallowing excess blood can irritate the stomach and cause vomiting. Local application of an ice pack to the forehead or back of the neck or sucking an ice cube has seen widespread practice, but has been shown to not have any statistically significant effects on nasal mucosal blood flow.<ref>[http://www.ingentaconnect.com/content/bsc/cot/2003/00000028/00000006/art00013 IngentaConnect Efficacy of ice packs in the management of epistaxis<!-- Bot generated title -->]</ref>. In the past, it was commonly thought that the ice would help by promoting constriction of local blood vessels and thus reducing blood flow to slow down the bleed. Do not pack the nose with tissues or gauze. <ref>{{cite web|url=http://www.rush.edu/rumc/page-1098987337863.html|title=Rush University Medical Center|accessdate=2008-03-05}}</ref>
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| The local application of a vasoconstrictive agent has been shown to reduce the bleeding time in benign cases of epistaxis. The drugs [[oxymetazoline]] or [[phenylephrine]] are widely available in over-the-counter nasal sprays for the treatment of [[allergic rhinitis]], and may be used for this purpose.<ref name="pmid2676467">{{cite journal |author=Guarisco JL, Graham HD |title=Epistaxis in children: causes, diagnosis, and treatment |journal=Ear Nose Throat J |volume=68 |issue=7 |pages=522, 528–30, 532 passim |year=1989 |pmid=2676467 |doi=}}</ref>
| | [[Epistaxis history and symptoms| History and Symptoms]] | [[Epistaxis physical examination | Physical Examination]] | [[Epistaxis laboratory findings | Laboratory Findings]] | [[Epistaxis ultrasound|Ultrasound]] | [[Epistaxis other diagnostic studies|Other diagnostic studies]] |
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| Other products available promote coagulation include Coalgan (in Europe) or NasalCEASE (in the US). These are a calcium alginate mesh that is inserted in the nasal cavity to accelerate coagulation.
| | ==Treatment== |
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| | [[Epistaxis medical therapy|Medical therapy]] | [[Epistaxis surgery|Surgery]] | [[Epistaxis primary prevention|Primary prevention]] | [[Epistaxis secondary prevention|Secondary prevention]] | [[Epistaxis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Epistaxis future or investigational therapies|Future or Investigational Therapies]] |
| If these simple measures do not work then medical intervention may be needed to stop bleeding, possibly by an [[otolaryngology|otolaryngologist (ENT doctor)]].
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| In the first instance this can take the form of chemical cautery of any bleeding vessels or packing of the nose with ribbon gauze or an absorbent dressing. Such procedures are best carried out by a medical professional. Chemical cauterisation is most commonly conducted using local application of silver nitrate compound to any visible bleeding vessel. This is a painful procedure and the nasal mucosa should be anaesthetised first, preferably with the addition of topical adrenaline to further reduce bleeding. If bleeding is still uncontrolled or no focal bleeding point is visible then the nasal cavity should be packed with a sterile dressing, which by applying pressure to the nasal mucosa will tamponade the bleeding point. Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anaesthesia to identify an elusive bleeding point or to directly ligate (tie off) the blood vessels supplying the nose. These blood vessels include the sphenopalatine, anterior and posterior ethmoidal arteries. More rarely the maxillary or external carotid artery can be ligated. The bleeding can also be stopped by intra-arterial embolization using a catheter placed in the groin and threaded up the aorta to the bleeding vessel by an interventional radiologist. Continued bleeding may be an indication of more serious underlying conditions.<ref>[http://www.nlm.nih.gov/medlineplus/ency/article/003106.htm MedlinePlus Medical Encyclopedia: Nosebleed<!-- Bot generated title -->]</ref>
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| Chronic epistaxis resulting from a dry nasal mucosa can be treated by spraying [[Saline (medicine)|saline]] in the nose up to three times per day.
| | ==[[Epistaxis case study one|Case #1]]== |
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| Application of a topical [[antibiotic]] ointment to the nasal mucosa has been shown to be an effective treatment for recurrent epistaxis.<ref name="pmid11843924">{{cite journal |author=Kubba H, MacAndie C, Botma M, Robison J, O'Donnell M, Robertson G, Geddes N |title=A prospective, single-blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood |journal=Clin Otolaryngol Allied Sci |volume=26 |issue=6 |pages=465–8 |year=2001 |pmid=11843924 |doi=}}</ref> One study found it to be as effective as nasal cautery in the prevention of recurrent epistaxis in patients without active bleeding at the time of treatment (both had a success rate of approximately 50 percent.)<ref name="pmid10384851">{{cite journal |author=Murthy P, Nilssen EL, Rao S, McClymont LG |title=A randomised clinical trial of antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis |journal=Clin Otolaryngol Allied Sci |volume=24 |issue=3 |pages=228–31 |year=1999 |pmid=10384851 |doi=}}</ref>
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| Nosebleeds are rarely dangerous unless prolonged and heavy. Nevertheless they should not be underestimated by medical staff. Particularly in posterior bleeds a great deal of blood may be swallowed and thus blood loss underestimated. The elderly and those with co-existing morbidities, particularly of blood clotting should be closely monitored for signs of shock.
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| Recurrent nosebleeds may cause [[anemia]] due to [[iron deficiency]].
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| As a summary; first aid of epistaxis include:
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| * Tilt head forward, apply continuous pressure by pinching nares together to avoid posterior blood drainage (5-10 minutes)
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| * Apply silver nitrate to bleeding vessel (if identified)
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| * Possible blood transfusions
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| * Platelet transfusion, vitamin K, fresh frozen plasma, clottin factor replacement for bleeding disorders (if necessary)
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| * Possible ENT consult
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| ===Surgical or device based therapy===
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| * Nasal balloon or Foley catheter for posterior bleeds
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| ==References==
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| <div class="references-small">
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| <references/>
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| </div>
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| ==See also== | | ==See also== |
| * [[Kiesselbach's plexus]] | | * [[Kiesselbach's plexus]] |
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| ==External links==
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| * [http://www.nlm.nih.gov/medlineplus/ency/article/000020.htm National Library of Medicine] - Describes causes, solutions, and prevention of nosebleeds | | * [http://www.nlm.nih.gov/medlineplus/ency/article/000020.htm National Library of Medicine] - Describes causes, solutions, and prevention of nosebleeds |
| * [http://stop-nosebleeds.org stop-nosebleeds.org] - describes the Thumbs Up alternate method of stopping nose bleeds | | * [http://stop-nosebleeds.org stop-nosebleeds.org] - describes the Thumbs Up alternate method of stopping nose bleeds |
| * [http://www.drtbalu.com/epistaxis.html drtbalu otolaryngology online]
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| * [http://www.healthninjas.com/remedies/nosebleeds.shtml Natural Remedies for Nosebleeds]
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| * [http://nosebudd.com/ NoseBudd- Helps Stop NoseBleeds Cold]
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| {{Symptoms and signs}}
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| [[bg:Епистаксис]]
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| [[de:Epistaxis]]
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| [[es:Epistaxis]]
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| [[fr:Épistaxis]]
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| [[id:Hidung berdarah]]
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| [[it:Epistassi]]
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| [[ms:Hidung berdarah]]
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| [[nl:Bloedneus]]
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| [[ja:鼻血]]
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| [[pt:Epistaxe]]
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| [[sv:Näsblod]]
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| [[vi:Chảy máu cam]]
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| [[zh:流鼻血]]
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| [[Category:Signs and symptoms]] | | [[Category:Signs and symptoms]] |
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| [[pl:Krwawienie z nosa]]
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |
