Is epistaxis (nosebleed) a concern following a head injury?

From the Guidelines

Epistaxis following a head injury is a concerning symptom that warrants immediate medical attention, especially if accompanied by signs of brain injury, obvious nasal deformity, or signs of facial fracture. According to the 2024 American Heart Association and American Red Cross guidelines for first aid 1, a person with epistaxis due to trauma should seek medical attention if they experience these signs. The guidelines emphasize the importance of seeking medical help in such cases, classified as a Class 1 recommendation with evidence from expert opinion (C-EO) 1.

Key considerations for medical evaluation include:

• Signs of brain injury
• Obvious nasal deformity
• Signs of facial fracture
• Profuse or persistent bleeding
• Clear fluid drainage from the nose, which could indicate a basilar skull fracture and risk of meningitis
• Other concerning signs like bruising around the eyes (raccoon eyes), bruising behind the ears (Battle's sign), severe headache, confusion, loss of consciousness, or neurological symptoms

While the guidelines provide recommendations for managing epistaxis in general, such as applying manual pressure to the nostrils for 10 to 15 minutes 1, the context of a head injury makes it crucial to prioritize medical evaluation over home management. This approach is supported by the guideline's recommendation for individuals with epistaxis due to trauma to seek medical attention under specific conditions, highlighting the potential for serious underlying injuries 1.

From the Research

Epistaxis Following Head Injury

• Epistaxis, or nosebleed, is a common condition that can be caused by various factors, including head injury 2, 3, 4.
• The management of epistaxis typically involves an assessment of vital signs, mental status, and airway patency, followed by compressive therapy, and possibly the use of topical agents such as oxymetazoline or tranexamic acid 2, 5.
• In some cases, particularly those involving posterior epistaxis, more invasive treatments such as nasal packing, cauterization, or surgical ligation may be necessary 2, 6.
• The use of tranexamic acid has been shown to be effective in achieving hemostasis in patients with epistaxis, with some studies suggesting it may be more effective than traditional treatments such as oxymetazoline 3, 5.
• Embolization is also a treatment option for intractable epistaxis, with a success rate of approximately 90% and a major complication rate of around 2% 6.

Treatment Options

• Compressive therapy is often the first step in managing epistaxis, and can be supplemented with topical agents such as oxymetazoline or tranexamic acid 2, 5.
• Nasal packing, either anterior or posterior, may be necessary in some cases, particularly those involving posterior epistaxis 2, 6.
• Cauterization, either chemical or electrical, can also be used to control bleeding in patients with epistaxis 2, 6.
• Surgical ligation or embolization may be necessary in severe cases of epistaxis that are unresponsive to other treatments 6.

Considerations

• Epistaxis can be a sign of an underlying condition, such as a coagulation disorder, and therefore requires careful evaluation and management 4.
• The choice of treatment for epistaxis will depend on the severity and location of the bleeding, as well as the patient's overall health status 2, 3, 5, 6.