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Epistaxis
From WikEM
Contents
Background
Types
- Anterior
- 90% of nosebleeds
- Occur in anterior septum (Kiesselbach plexus)
- Can visualize with anterior rhinoscopy
- Posterior
- 10% of nosebleeds
- Occur from nasopalatine branch of sphenopalatine artery
- Cannot visualize without endoscope
Risk factors
- Digital trauma
- Rhinosinusitis
- Anticoagulant/antiplatelet use
- Trauma
- Neoplasia
- cold weather (indoor heating systems create dry air)
- Hypertension (does not cause bleeding but prolongs existing bleeding)
- Osler-Weber-Rendu aka hereditary hemorrhagic telangiectasia (HHT)
Clinical Features
Differential Diagnosis
Evaluation
Anterior versus posterior hemorrhage
- Assume posterior if measures to control anterior bleeding fail
- Posterior bleeding associated with:
- Coagulopathy
- Significant hemorrhage visible in posterior nasopharynx
- Sensation of blood dripping down throat
- Hemorrhage from bilateral nares
- Epistaxis uncontrolled with either anterior rhinoscopy or anterior pack
Management
Direct Nasal Pressure
- Have patient blow nose to expel clots or suction nose
- Instill topical vasoconstrictor (oxymetazoline or phenylephrine)
- Have patient apply direct pressure over cartilaginous area of nasal bridge (not the bony area)
- Patient must lean forward to avoid blood draining down nasopharynx thus preventing desired tamponade
Chemical Cauterization
- Consider if two attempts at direct pressure fail
- Only perform if the bleeding vessel is adequately visualized
- Anesthetize with cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
- Once bloodless field obtained, place silver nitrate just proximal to bleeding source
- Leave on for a few seconds at most
- Never cauterize both sides of the septum at one go (risk of septal perforation)
Thrombogenic Foams
- Apply Gelfoam or Surgicel on visualized bleeding mucosa
- Bioabsorbable so removal/antibiotics not needed
Anterior Nasal Packing
Only use if all of the above have failed
- Rapid Rhino
- Soak balloon with water(NOT saline) and insert along the floor of the nasal cavity
- Inflate slowly with air(NOT saline or water) until the bleeding stops
- Merocel
- Absorbent nasal tampon
- Coat tampon with water-soluble antibiotics ointment and insert along floor of nasal cavity
- If tampon has not expanded within 30s of placement, irrigate it in place with NS
- Moisten three times per day with saline or water until removal
- Traditional Packing
- Apply ribbon gauze in accordion-like manner
Tranexamic acid
- 500mg TXA applied to topical foam or non absorbable packing and inserted into nares.[1]
- Can stop bleeding as fast as 10 minutes
Posterior Nasal Packing
Only consider if all of the above have failed
- Associated with higher complication rates (pressure necrosis, infection, hypoxia)
- Temporizing measure while awaiting ENT support
- Consider nasal block as posterior packing is often very uncomfortable
- All posterior packing should be accompanied by anterior packing
- Rapid Rhino
- Inflate posterior balloon
- Foley catheter with 30-cc balloon
- Lubricate with topical antibiotic
- Advance transnasally until visualized in posterior oropharynx
- Inflate balloon with 7cc of saline; retract 2-3cm until lodged in post nasopharynx
- Inflate with additional 5-7cc of saline to complete the pack
- Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.
Disposition
Anterior Epistaxis
- consider checking Hgb to ensure no significant blood loss anemia
- Discharge after 1hr of observation
- Patients with therapeutic warfarin levels may continue medication
- Discontinue NSAIDs for 3-4d
- Possible amoxicillin-clavulanate if anterior packing was placed as prophylaxis for bacterial sinus infection or Toxic shock syndrome although no robust evidence base[2]
- ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
- admit if bilateral packing, symptomatic anemia, or anemia requiring transfusion
Posterior Epistaxis
- Admission to telemetry is strongly advised
- Posterior packing causes vagal stimulation, increasing risk of dysrhythmia and bronchoconstriction
Complications
- Recurrent unilateral epistaxis has been described in association with malignancy [3][4]
- Toxic Shock Syndrome
References
- ↑ Zahed R. et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial.Am J Emerg Med. 2013 Sep;31(9):1389-92
- ↑ Cohn B. Are prophylactic antibiotics necessary for anterior nasal packing in epistaxis? Ann Emerg Med. 2015 Jan;65(1):109-11
- ↑ Primary malignant melanoma of the nose: a rare cause of epistaxis in the elderly. PDF
- ↑ Kaposiform hemangioendothelioma arising in the ethmoid sinus of an 8‐year‐old girl with severe epistaxis PDF
