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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Most epistaxis is anterior from Kiesselbach plexus and responds to firm continuous compression of the soft nose for 10-15 minutes
- Initial management: airway/hemodynamic assessment, sit forward, clear clots, topical vasoconstrictor, then directed compression
- Visible anterior bleeding source after control can be treated with silver nitrate cautery; do not cauterize both sides of septum
- Posterior epistaxis is more common in older adults, hypertension, anticoagulation, and may require posterior packing or endoscopic arterial ligation
- Recurrent unilateral epistaxis, obstruction, facial pain, or neck mass requires evaluation for neoplasm
Overview
Epistaxis is bleeding from the nasal cavity. Most cases are anterior and arise from Kiesselbach plexus on the anterior nasal septum. Posterior epistaxis arises from branches of the sphenopalatine artery and is more likely to be brisk, bilateral through the nares or into the throat, and difficult to control. Management is stepwise: stabilize the patient, compress correctly, use topical vasoconstriction and anesthesia, identify and cauterize an anterior source if visible, then pack or refer if bleeding persists.
Epidemiology
Epistaxis is common across all ages, with peaks in children and older adults. Predisposing factors include dry air, nose picking, allergic rhinitis, URI, intranasal corticosteroid misdirection, septal deviation/perforation, facial trauma, anticoagulants, antiplatelets, thrombocytopenia, liver disease, hereditary hemorrhagic telangiectasia, and tumors. Hypertension may make bleeding harder to control but is not usually the sole cause.
Clinical Features
Symptoms
Visible anterior nasal bleeding, often unilateral
Blood dripping into the throat, coughing blood, or bilateral bleeding suggests posterior source
Lightheadedness, syncope, dyspnea, chest pain, or heavy ongoing bleeding
Recurrent spontaneous epistaxis with mucocutaneous telangiectasias suggests hereditary hemorrhagic telangiectasia
Unilateral obstruction, facial numbness, cranial neuropathy, or neck mass
Bleeding after facial trauma with septal swelling suggests septal hematoma
Signs
Anterior septal bleeding point on rhinoscopy
Ongoing posterior pharyngeal blood despite anterior control suggests posterior epistaxis
Pallor, tachycardia, hypotension, or orthostasis suggests significant blood loss
Septal perforation, crusting, or ulceration may reflect trauma, cocaine, vasculitis, or iatrogenic injury
Septal hematoma: fluctuant septal swelling after trauma — urgent drainage
Investigations
First-line
Focused examination after clearing clotsUse suction/blowing and topical vasoconstrictor/anesthetic to identify anterior bleeding site
Medication reviewAnticoagulants, antiplatelets, NSAIDs, intranasal sprays, herbal supplements
Second-line
CBCIf heavy, recurrent, prolonged, symptomatic, or anticoagulated bleeding
PT/INR, aPTT, platelet countIf anticoagulant use, liver disease, bleeding disorder, or severe/recurrent epistaxis
Type and screenIf hemodynamically unstable, posterior epistaxis, or substantial blood loss
Specialist
Nasal endoscopyRecurrent, unilateral, posterior, or unexplained epistaxis; needed when source not seen
CT/MRIIf mass, facial trauma, sinus tumor, juvenile nasopharyngeal angiofibroma, or skull-base pathology suspected
ENT/interventional radiologyPosterior packing failure, recurrent severe epistaxis, arterial ligation, or embolization
1
First-line control
- Sit upright and lean forward to avoid swallowing blood
- Firm continuous compression of the lower soft third of the nose for 10-15 minutes; do not pinch the bony bridge
- Apply topical oxymetazoline or phenylephrine; clear clots before compression
- Assess airway, breathing, circulation; establish IV access for severe bleeding
2
Anterior source visible
- Topical anesthetic, then silver nitrate cautery to a localized bleeding point once bleeding is controlled
- Cauterize one side only to reduce septal perforation risk
- Moisturization with saline gel/petrolatum and avoidance of trauma after control
3
Packing and posterior bleeding
- Anterior nasal packing if compression/cautery fails or no visible source
- Posterior balloon packing or Foley-based packing for suspected posterior epistaxis; admit with monitoring due to hypoxia, arrhythmia, and rebleeding risk
- Endoscopic sphenopalatine artery ligation or embolization for refractory posterior epistaxis
4
Anticoagulation and prevention
- Do not automatically reverse anticoagulation for mild controlled epistaxis; consider thrombotic risk
- Reverse or hold anticoagulation for life-threatening or uncontrolled bleeding in coordination with appropriate specialists
- Treat contributing dryness, allergic rhinitis, septal trauma, or uncontrolled hypertension
Complications
- Hypovolemia/anemia: Severe or posterior bleeding can be substantial
- Aspiration: Especially if altered mental status or posterior bleeding
- Septal perforation: From bilateral cautery, trauma, cocaine, or chronic crusting
- Toxic shock syndrome: Rare complication of nasal packing
- Missed tumor: Recurrent unilateral epistaxis with obstruction requires endoscopic evaluation
USMLE Step 2 CK Exam Tips
- 1First step in stable anterior epistaxis: pinch the soft nasal alae continuously while leaning forward
- 2Do not pinch the bony nasal bridge; it does not compress Kiesselbach plexus
- 3Silver nitrate is used only after bleeding is controlled and a bleeding point is visible
- 4Posterior epistaxis = blood in throat, bilateral bleeding, older anticoagulated patient — ENT and packing/admission
- 5Cauterizing both sides of septum risks septal perforation
- 6Septal hematoma after nasal trauma needs urgent drainage to prevent cartilage necrosis
- 7Recurrent unilateral epistaxis plus obstruction = evaluate for malignancy or vascular tumor
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