Epistaxis
- Through history and/or physical examination, assess the hemodynamic stability of patients with epistaxis.
- While attending to active nose bleeds, recognize and manage excessive anxiety in the patient and accompanying family.
- In a patient with an active or recent nosebleed, obtain a focused history to identify possible etiologies (e.g., recent trauma, recent respiratory tract infection, medications).
- In a patient with an active or recent nosebleed:
- Look for and identify anterior bleeding sites
- Stop the bleeding with appropriate methods.
- In a patient with ongoing or recurrent bleeding in spite of treatment, consider a posterior bleeding site.
- In a patient with a nosebleed, obtain lab work only for specific indications (e.g., unstable patient, suspicion of a bleeding diathesis, use of anticoagulation).
- In a patient with a nose bleed, provide thorough aftercare instructions (e.g., how to stop a subsequent nose bleed, when to return, humidification, etc.)
General Overview
General Overview
- Most (90%) anterior bleed from Kiesselbach's plexus/Little's Area (internal/external carotid)
- Posterior bleeds from posterolateral branches of sphenopalatine artery
Causes
Causes
- Local trauma (Picking, foreign body, infection, allergic rhinitis)
- Environmental (Dry)
- Iatrogenic (NG tube)
- Medicine (Topical steroids, antihistamines, anticoagulants)
- Cocaine
- Coagulopathies (platelet disorders, vW disease, hemophilia)
- Vascular abnormalities (hereditary hemorrhagic telangiectasia [Osler-Weber-Rendu], carotid artery aneurysm)
- Neoplasm (nasal neoplasm)
Note: Hypertension controversial
History
History
- Trauma (r/o fracture)
- Bleeding history (including previous epistaxis and management)
- Medication (anticoagulants, nasal sprays/medication), Drugs (cocaine)
- Red flags (neopastic)
- Headache, facial pain/swelling, nasal blockage, rhinorrhea, anosmia, otalgia, loose teeth
Management
Management
Initial
Initial
- Comfort in calm, quiet area to decrease anxiety
- Position sitting forward, mouth open
- Pressure by pinching (soft cartilaginous) anterior nose for 15-20mins (nasal ala against septum)
- Consider ice pack to nape of neck for reflex vasoconstriction (weak evidence - expert opinion)
- If stabilized, consider topical antiseptic ointment up to two weeks
Hospital
Hospital
- ABC, Vitals
- Consider definitive airway, fluid resuscitation
- Consider labs if unstable or suspect coagulopathy: CBC, INR, Blood type, cross match, consider LFT/creat
- Consider wearing gown, gloves, mask, face shield
- Suction (Blow nose to remove clots or use angled Frazier 10-12F suction)
- Vasoconstriction
- Topical or soaked cotton vasoconstrictors x 5-10 mins (eg. lidocaine, phenylephrine, epinephrine, cocaine, oxymetazoline)
- Consider Tranexamic acid through atomizer and 15 minutes of external compression
- Cautery if bleeding source visible by nasal speculum
- Suction and dry prior
- Silver nitrate until gray precipitate
- Only cauterize one side of septum (if both sides cauterized - risk of perforation)
- Electrocautery usually done by ENT after local anesthesia
- Packing
- Anterior packing (traditional vaseline gauze, compressed sponge/tampon, balloon, absorbable materials)
- Admission/ENT consult if bilateral packing needed
- Posterior packing (posterior source suggested in failure to visualize anterior source, bleeding from both nares, and blood in posterior pharynx)
- Analgesia
- Double balloon catheters or foley with 30mL balloon
- Admission to monitor for hypoxia
- Leave packing 1-3 days prior to removal, can consider prophylactic antistaphylococcal antbiotics to prevent Toxic Shock Syndrome
- Consider F/U ENT 48-72h
- Anterior packing (traditional vaseline gauze, compressed sponge/tampon, balloon, absorbable materials)
- Consider coagulopathy
- Refer to ENT/surgery for endoscopic ligation/embolization in severe cases
Prevention of re-bleeding
Prevention of re-bleeding
- Avoid activities
- Blowing/picking nose
- Open mouth when sneezing
- Heavy lifting/strenuous exercise
- Drinking alcohol/hot drinks
- Stop smoking/alcohol/cocaine
- Nose care
- Humidifier
- Petroleum jelly (Vaseline) gently applied by Q-tip TID x 10d for dryness
- Consider (low evidence) topical antibacterial (mupirocin) or bacteriostatic (bacitracin) ointment
- Direct nasal sprays away from septum
- Consider holding aspirin/antiplatelets x 6 days, NSAIDs x 3 days
References:
- Ann Emerg Med 2019. Tranexamic Acid. https://www.ncbi.nlm.nih.gov/pubmed/31080025
- Guthrie K. http://lifeinthefastlane.com/epistaxis/
- The Royal Children's Hospital Melbourne. Epistaxis. http://www.rch.org.au/clinicalguide/guideline_index/Epistaxis/
- Yai S. An update on epistaxis. Sept 2015. http://www.racgp.org.au/afp/2015/september/an-update-on-epistaxis
- Kucik CJ, Clenney T. Management of Epistaxis. Am Fam Physician. 2005 Jan 15;71(2):305-311. http://www.aafp.org/afp/2005/0115/p305.html