Epistaxis is a common presentation, especially amongst the young and elderly population. Knowing the basic management, red flags, and when to escalate is important particularly in acute situations!
A bit of background
- Epistaxis can have an anterior or posterior source; the majority of bleeds originate anteriorly from Kiesselbach’s plexus (Little’s area)
- Posterior bleeds generally arise from branches of the sphenopalatine artery
- Non-traumatic bleeds can be a consequence of ageing, with thinner and drier nasal mucosa
- Watch out for rare causes: hereditary haemorrhagic telangiectasia (HHT), neoplasms, coagulopathies, liver disease
Anatomy of Nasal Blood Supply
Anterior Bleeds
- More common
- Initially blood comes from one nostril
- Usually clinically obvious
Posterior Bleeds
- Can be asymptomatic
- Can present insidiously as haematemesis, anaemia, melaena, haemoptysis
- Rarely can result in sudden, massive bleeding
- A patient may report swallowing blood as an initial symptom
Initial management
- ABCDE!
- Sit the patient with their head leaning forward
- Ice packs on forehead and/or nape of neck
- Hold nares (fleshy part of nose) firmly for 20 minutes
- Make sure they don’t swallow blood! (it’s emetogenic)
- Apply bolster beneath the nose to soak up any subsequent ooze
- Onset and duration
- Preceding trauma?
- Frequency of bleeds
- Previous hospitalisation/treatment for epistaxis
- Systems review: any skin rashes/bruising/bleeding elsewhere (urine, faeces etc.)
- Medical history: HTN / bleeding disorders
- Social history: smoking (irritant), alcohol, recreational drug use (cocaine/inhalants)
- Medications review: NSAIDs, aspirin, anticoagulants and indication
- Family history: coagulation disorders
If the first line fails
- Consider calling ENT for advice/review
- If you feel comfortable to do so, insert a cotton ball soaked in local anaesthetic/adrenaline (topical vasoconstrictors) into nose then remove
- If an anterior bleeding site is found, the next step is cautery with silver nitrate sticks
- Consider calling ENT if you have never done this before or if you do not feel comfortable
- In practice, gently press the stick over the bleeding site. Take care not to do it repeatedly or on both sides of the septum as risks septal perforation.
- If cautery fails, blood is gushing out, or if suspecting posterior bleed urgently call ENT for insertion of a nasal pack (unless you are trained to do so)
- Before inserting a nasal pack (e.g. Rapid Rhino) ensure all blood and clots and cleared
Inserting a nasal pack
- Choose appropriate size of pack (anterior 5.5cm / ant-post 7.5cm / posterior 9cm)
- Ensure to insert it horizontally and not upwards, as following nasal anatomy
Associated care
- IV access and bloods (FBC, INR/clotting profile if the patient is on an anticoagulant, consider group & save)
- Usually, continue warfarin or aspirin if the bleeding stops with simple measures (i.e. anterior pack)
- However, if bleeding is torrential or uncontrolled anticoagulation, consider stopping anticoagulant and reversal agent
When to call for help
- If you are concerned, the bleeding is large volume, the patient appears compromised in any way
- Patients who have had trauma or have deformed anatomy
- Continued bleeding despite simple measures
After nasal packing
- Admit patients who have been packed
- Start analgesia
- Control hypertension
- Monitor for 24-48 hours depending on local guidelines
- If pack stays in for longer, start PO prophylactic antibiotics
On Discharge
- Following pack removal, start antiseptic cream (e.g. Naseptin: 1 application BD for 14 days) and attempt cautery for any anterior bleeding sites spotted
- Advise patients:
- Not to blow/pick nose
- Avoid hot drinks and showers
- Avoid strenuous activity/exercise
- Re-attend if further bleeding uncontrolled after 20 minutes
Surgical Escalation
- If bleeding persists despite packing or after pack removal (>24h), the patient may require sphenopalatine artery ligation. Involve an ENT registrar/consultant.
References & Useful Links
- https://cks.nice.org.uk/epistaxis-nosebleeds
- https://entsho.com/epistaxis
- http://www.emdocs.net/emergency-department-management-posterior-epistaxis/
Dr Yueqi Ge
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1 thought on “Epistaxis”
Very informative