Epistaxis

Background

  • Epistaxis is usually from Little’s area (90%), which is on the septal wall anteriorly and contains Kiesselbach plexus of vessels. 10% occur posteriorly, along the nasal septum or lateral nasal wall.
  • Nasal septum blood supply is from the internal carotid +  external carotid
  • The bleeding is usually venous, is of brief duration and is often recurrent.
  • Common between ages of 2-10 and 50-80 years old, results from factors that damage the nasal mucosal lining, affect the vessel walls, or alter the coagulability.

1 Through history and/or physical examination, assess the hemodynamic stability of patients with epistaxis.
2 While attending to active nose bleeds, recognize and manage excessive anxiety in the patient and accompanying family.

3 In a patient with an active or recent nosebleed, obtain a focused history to identify possible etiologies (e.g., recent trauma, recent upper respiratory infection, medications).

Causes

Local Trauma:
  • nose picking
  • facial trauma
  • foreign bodies, NG tube insertion, nasotracheal intubation
  • sneezing, coughing, straining
Friable nasal mucosa:
  • URTI
  • drying of mucosa – prolonged inhalation of dry air (oxygen), dry cold conditions (winter)
  • Intranasal steroids, antihistamines, snorting cocaine, solvent inhalation (huffing)
Coagulopathies:
  • Von Willebrand dz, haemophilia A & B, thrombocytopenia, plt disorders
  • Liver disorder, renal failure, splenomegaly, chronic EtOH use, AIDs
  • Anticoagulants: ASA, warfarin, platelet inhibitors
Vascular Abnormalities:
  • Sclerotic vessels, hereditary haemorrhagic telangiectasia, AV malformation, aneurysms
  • nasal polyps, neoplasm, septal perforation / deviation
  • Endometriosis
HTN
  • controversial, rarely a direct cause, but epistaxis more common in HTN pt (? vascular fragility from HTN)

Assessment

History:
  • Laterality, duration, frequency, severity (EBL), and recurrent?
  • Contributing or inciting factors
  • PMH: easy bruising, past history of bleeding after surgical challenges (eg dental extractions)
  • Family history of bleeding disorder, menorrhagia, recurrent epistaxis
  • Meds: eg NSAID’s, nasal sprays, nasal medication

4 In a patient with an active or recent nosebleed, a) Look for and identify anterior bleeding sites, b) Stop the bleeding with appropriate methods.
5 In a patient with ongoing or recurrent bleeding in spite of treatment, consider a posterior bleeding site.

Physical Exam – anterior vs posterior bleed
  • Suctioning or blowing of the nose to clear away clots, and application of topical vasoconstrictors or anaesthetics will help with visualization
  • Gently insert nasal speculum and spread naris vertically with a good light source
  • A posterior bleeding is suggested by
    • failure to visualize an anterior source
    • bleeding from both nares
    • the visualization of blood in the posterior pharynx.

6 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)

Investigations:
  • If large amounts of bleeding, CBC (Hgb level), and a group and hold in case transfusion is required.
  • INR if taking warfarin.
  • Coagulation studies (not routine) only in patients with a known coagulopathy or chronic liver disease
  • If past medical history warrants further investigation (renal failure = U&E, chronic alcohol abuse = LFTs), rarely change Tx
  • CT scan is indicated if neoplasm suspected, by ENT usually.

Management

Resuscitation and Assessment:
  • Airway – assess for airway compromise (e.g. if facial trauma), ETT prn
  • Breathing – RR, depth of breathing, O2 through non rebreather mask. (occluded = noisy)
  • Circulation – HR, BP, cap refill, 2 big bore IV, Group and Hold/ Crossmatch,  FBE, Clotting
  • Disability – monitor LOC
  • Exposure – keep pt warm to prevent coagulopathy & examine other injuries in trauma cases
Stop the bleeding:
  • if signs of shock refer to Resuscitation guideline
  • try simple measures first
  • consider early ENT opinion if severe or difficult to stop

7 In a patient with a nosebleed, provide thorough aftercare instructions (e.g., how to stop a subsequent nose bleed, when to return, humidification, etc.)

Simple measures:
  • continuous pressure on the anterior portion of the nose (avoid the nasal bones by pressing distally, the nasal ala against the septum) for 15-20 minutes 
  • patient should be sitting up with head in comfortable position – prevents swallowing or aspirating any blood as fresh blood is irritating to the stomach and will cause N/V
  • if this stops the bleeding, patient can be discharged with education
  • if dry cracked mucosa contributing, petroleum gel (eg Vaseline) should be applied until healing  (6 weeks)
  • for frequent recurrences consider an ENT review as an outpatient
Persistent Bleeding:
  • often due to inadequate treatment/pressure
determine the site of bleeding
  • Ask pt to blow nose +/- with suction available to remove clots
  • vasoconstrictors applied via spray or soaked cotton to Little’s area
    • Lidocaine + 1:1000 Epi, Co-PHenylcaine, Oxymetazoline, cocaine
  • if bleeding controlled – petroleum jelly
  • if bleeding remains uncontrolled, cautery or packing may be required
Cautery:
  • haemostasis must be achieved first via pressure/vasoconstrictors
  • chemical cautery can be achieved by applying the tip of the silver nitrate stick to the small area around the bleeding site
    • suction the bleeding site – as dry as possible to maximize effectiveness
    • Warn about localized pain on application
    • cauterize one septum only (risk of perforation)
  • overzealous cautery can result in ulceration and perforation
Hints for nasal cautery
  • Never attempt under the age of four years, as it is unlikely that the child will co-operate.
  • Allow time for anaesthesia to work
  • Have the child lying down
  • Have a good headlight
  • Silver nitrate sticks may not require moistening with water.  Excessive moistening may lead to silver nitrate solution running and staining the nares
  • Give instructions about:
    • Continue petroleum gel bid. for one week
    • No nose blowing for one week
    • No nose picking
If these measures fail, nasal packing may be required:
  • If site of bleeding is known, insert unilateral anterior nasal pack
  • For persistent bleeding, urgent ENT consultation is warranted
  • Bilateral anterior packing or any posterior packing should not be attempted without ENT consultation
Anterior nasal packing
  1. Traditional Vaseline gauze packing – generally not used, need both ends of the gauze protrude from the nose to allow ease of removal.
  2. Compressed sponge / tampon: Merocel – insert then rehydrate by blood or NS. Not comfortable.
    • Coat with water soluble gel, grasp the string end with fingers or forceps.  Gently and quickly insert along the floor of the nasal cavity until the string reaches the nose.  If packing hasn’t expanded in 30 seconds, irrigate with 10ml of saline or water.  Tape the string to the nose and trim ends.
  3. Anterior epistaxis ballons: Rapid Rhino – outer layer of carboxycellulose (plt aggregation), with an inflatable ballon
  4. Absorbable materials – carboxymethycellulos sponges, calcium alginate dressing / wicks – inc toxic-shock syndrome
Posterior nasal packing
  • Analgesia is required
  • Double ballon catheter
    • The catheter is inserted to the back of the nasopharyngeal space, and then inflate the posterior balloon first and bring forward sealing off the postnasopharyngeal space. Then inflate the  anterior ballon to apply pressure to the internal cavity of the nose.
    • Saline is preferred over air to inflate balloon as air can leak out causing deflation and further rebleeding.
    • Avoid over-inflating ballon catheters as will cause increased discomfort, rupture of the ballon, or pressure necrosis of the nasal mucosa.
  • A foley catheter can be used 10-14 French with 30ml balloon as an alternative.

Disposition

  • Admit patients with posterior packing (↑ hypoxia & hypoventilation), requiring oxygen, and patients with difficult to manage bleeds.
  • Patient with anterior packing can generally be discharged home, with packing insitu, with follow up arranged in 48-72 in the ENT clinic. Provided prophylactic antibiotics and oral analgesia.
  • Patients with chronic epistaxis should receive medical followup to investigate anaemia from chronic blood loss, and coagulopathies.
  • Uncontrolled severe epistaxis can sometimes require endoscopic cautery, embolization or artery ligations, patients at risk should receive early ENT review.
  • Consider Tranexamic acid in severe epistaxis as it works as a potent competitive inhibitor of plasminogen activator and thus of the fibrinolytic system, and may therefore prevent clot disintegration and reduce the likleylihood of rebleed.

Follow up

  • Epistaxis controlled by simple measures can be followed up by GP
  • Unilateral anterior packing should be reviewed in the Emergency Department or by ENT within 48 hours.
  • Merocel® Nasal Tampons should be moistened with normal saline for ease of removal.
  • Recurrent unilateral epistaxis should prompt further investigation to r/o neoplasm

Reference:

http://lifeinthefastlane.com/epistaxis/

Clinical Practice Guidelines : Epistaxis.

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Posted in 36 Epistaxis, 99 Priority Topics, ENT, FM 99 priority topics

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