Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Epistaxis

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Epistaxis - Key Features

1. Through history and/or physical examination, assess the hemodynamic stability of patients with epistaxis.

Initial assessment:
Remember your ABC’s; your evaluation should always start with ensuring that there is an adequate airway and hemodynamic stability.

Vital Signs
CVS: Pallor, tachycardia, weak thready pulse, hypotension, depressed JVP, dry mucous membranes.
Resp: Tachypnea
Extremities: cool, clammy, mottled, prolonged cap refill, shut down.
CNS: Mental status changes, agitation, anxiety, confusion, combativeness, lethargy, coma.
GU: decreased urine output.
Systemic: Hypothermia

History: Quantify blood loss, duration, bleeding disorders, anticoagulation, CAD or other comorbid conditions.

2. While attending to active nose bleeds, recognize and manage excessive anxiety in the patient and accompanying family.

Patients often present with marked anxiety. Comfort, educate assess need for anxiolytics.

3. 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).

History: Duration, severity, frequency, quantity of blood loss, laterality. Contributing or inciting factors: trauma, nose picking, sinusitis, meds, drug use, environmental triggers. Nasal obstruction. Personal or family history of bleeding disorders, or easy bruising.

Common Causes of Epistaxis

Local: Chronic sinusitis, Epistaxis digitorum (nose picking), foreign bodies, intranasal neoplasm or polyps, irritants (e.g., smoking), medications (e.g., topical coticosteroids or antihistamines), rhinitis, septal deviation, septal perforation, trauma, illicit drug use, vascular malformations or talangectasia (e.g., Hereditary hemorrhagic telangectasia)
Systemic: Hemophilia, HTN (controversial), Leukemia, Liver disease, Renal disease, Platelet dysfunction, Thrombocytopenia, Medications (e.g., ASA, anticoagulants, Plavix, NSAIDS), alternative therapies (e.g., garlic, ginko, ginseng).


4. In a patient with an active or recent nosebleed:
a) Look for and identify anterior bleeding sites

More than 90% of bleeds occur along the anterior nasal septum at Kiesselbach’s area.
Epistaxis anatomy.png

Blood supply: External carotid through the superior labial branch of the facial artery and the terminal branch of the spenopalantine artery. Internal carotid through the anterior and posterior ethmoidal arteries.

Utilize universal precautions, gown, gloves, face shield. Ensure adequate lighting, head lamp, Frazier suction. Clear clots, have patient blow nose, may require use of forceps/suction. Examine nares utilizing nasal speculum. Try to identify the bleeding point. Bleeding may have to be better controlled to allow visualization: direct pressure/ice pack 15mins, gauze soaked with 4% cocaine or 4% lidocaine + oxymetalazoline.

b) Stop the bleeding with appropriate methods.

Consider need for IV. Apply direct pressure pinching anterior aspect of nose while leaning forward x 15 min. Place pledgets soaked in topical vasoconstrictors (oxymetazoline, cocaine) in the anterior nares. If vessel is identified cauterize using silver nitrate or electric cautery (cauterize only one side at once to prevent septal perforation). If refractory apply anterior nasal packing: petroleum jelly soaked gauze, a sponge composed of hydroxylated polyvinyl acetate that expands when wet (Merocel, Medtronic), an inflatable pack coated with hydrocolloid (Rapid Rhino, Arthrocare). Packs are left in place 1-3 days prior to removal. A variety of absorbable or degradable material that does not require formal removal is available and may be useful in individuals with coagulopathy. These include Sugicel, Gel foam, Avitene, Suriflo, FloSeal. These agents typically increase clot formation and provide some degree of tamponde. They form a slurry which is injected into the nares with a syringe. Complications of nasal packing include septal hematomas and abscesses, sinusitis, neurogenic syncope, pressure necrosis, and toxic shock syndrome. For prolonged packing consider the use of antistaphylococcal antibiotic ointment on packing materials.

5. In a patient with ongoing or recurrent bleeding in spite of treatment, consider a posterior bleeding site.

10% of bleeds occur posteriorly, along the nasal septum or lateral nasal wall. Blood supply: external carotid through the sphenopalantine branch of the internal maxillary artery.

Often treated by Otolaryngologist. Inflatable balloon such as epistat and foley catheter widely used for posterior packing. Traditional posterior gauze packs, introduced through the mouth and retracted back into the nasopharynx can also be used. The pack is retracted anteriorly and must provide tamponade in the area of the choanae and the sphenopalantine foramen. The anterior end is secured at the ala to ensure countertraction. When conservative measures fail embolization or surgical ligation of the offending vessel may be necessary.

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).

Most patients will not require any blood work. Based on severity of presentation, use of anticoagulation etc. consider obtaining CBC, PTT/INR, Blood type, cross match, may also consider obtaining renal fxn and LFT’s.

7. 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.)

How to stop the bleed: lean forward and spit out blood. Apply pressure by squeezing the soft part of the nose not he boney segment. Hold for 10-15 minutes. Avoid packing as will likely rebleed on removal. If bleeding persists after 20 mins of direct pressure seek medical attention.

Prevention: Don’t pick your nose, don’t use cocaine, quit smoking. Identify specific triggers such as nasal spray, alternative therapies. Apply petroleum jelly to nares BID to relieve dryness and irritation. Consider use of a humidifier at night. Avoid forceful nose blowing.

Study Guide

Epistaxis

Resources

Kucik CJ, Clenney T. Management of epistaxis. American family physician. 2005; 71(2): 305-311.
Schlosser RJ. [http://www.nejm.org/doi/full/10.1056/NEJMcp0807078 Epistaxis'; clinical practice. NEJM. 2009; 360(8): 784-789.