Epistaxis

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

Blood Supply to the Nose and Littles Area
From TeachMeAnatomy.info

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

  1. ABCDE!
  2. Sit the patient with their head leaning forward
  3. Ice packs on forehead and/or nape of neck
  4. Hold nares (fleshy part of nose) firmly for 20 minutes
  5. Make sure they don’t swallow blood! (it’s emetogenic)
  6. Apply bolster beneath the nose to soak up any subsequent ooze
Important history to ask
  • 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
Figure 4
From EmDocs.net

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

Dr Yueqi Ge

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