Epistaxis

Overview

•Little's area (Kiesselbach's plexus) - anteromedial nasal septum; source of ~95% of nosebleeds

•Fed by four arteries: anterior ethmoid, sphenopalatine, greater palatine, superior labial

•Mucosa here is thin, highly vascular, and exposed to trauma/turbulent airflow - explains why bleeding can be brisk

•Posterior epistaxis - less common; suggested by bilateral or oral bleeding; associated with atherosclerosis and anticoagulation in older patients

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Anterior nasal septum (Little's area) is the most likely source in the vast majority of epistaxis cases - including in anticoagulated patients without nasal pathology.

Management

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When the bleeding site is NOT visible, anterior packing is the correct next step - not cautery. Cautery requires a visible vessel.

Anticoagulation and Adjuncts

•INR - check if on warfarin; admit if bleeding difficult to control with supratherapeutic INR

•Do not routinely reverse anticoagulation for epistaxis alone; do not stop without specialist advice

•Tranexamic acid (topical or oral) - adjunct in recurrent or difficult-to-control epistaxis; inhibits fibrinolysis

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Intranasal epinephrine causes vasoconstriction and may help prevent re-bleeding once initial haemostasis is achieved, but is not useful during active heavy bleeding.