Epistaxis
Red flags
Patients on full dose anticoagulants, e.g. warfarin or heparin
Patients who continue to bleed despite effective packing
Trauma patients - internal anatomy may be deformed
When to involve the ENT Registrar
Patients who continue to bleed despite effective anterior +/- posterior packing
Who to admit
Patients who have required nasal packing (some departments may discharge patients who have had an absorbable pack or have a protocol for younger low risk patients to go home with packing in situ to be brought back the following day - check your department).
Older, frail patients who may need help at home or live alone, especially if it is late at night
NB: Patients with recurrent smaller-volume bleeds that respond to first aid are suitable for emergency clinic.
NB: Those bleeding heavily OR for more than 20 minutes despite first aid measures should be seen in A&E and NOT the ward treatment room
Assessment and recognition
Try to establish where the bleeding is coming from.
ANTERIOR
The vast majority of bleeding is anterior. This frequently originates from Little's area on the anterior septum (visible on anterior rhinoscopy), or sometimes from the lateral nasal wall (the "S-point")
Initially comes out of one nostril only
Predominantly comes out of the anterior nares, but some can trickle into the throat, especially on tilting the head backwards, applying first aid or when the nose is full of clots
POSTERIOR
A small minority of bleeds are posterior
Bleeding goes down the throat and out of both nostrils
Continues briskly despite anterior packing
AETIOLOGY AND RISK FACTORS
Non-traumatic epistaxis is primarily a consequence of ageing. With age, the nasal mucosa loses thickness and the ability to remain moist in the face of drying. Frequently, iatrogenic drying (nasal oxygen), medications (anticoagulants/antiplatelet drugs) and minor trauma (nose blowing or picking) are enough to precipitate bleeding.
Traumatic epistaxis may be due to bleeding from the anterior ethmoidal artery, and usually settles soon after the initial blow. Intractable traumatic epistaxis is rare and may need urgent anterior ethmoidal artery ligation.
Rare causes include sinonasal neoplasms, coagulopathy and hereditary haemorrhagic telangiectasia (HHT).
Since HHT is hereditary, whole families are usually well-known to the ED and ENT teams. Try to avoid packing patients with HHT, as this can convert a single bleeding point to multiple bleeding points.
The real relationship between hypertension and epistaxis isn't clear. Many patients with otherwise normal blood pressure probably undergo a sympathetic response during a nosebleed, and can be erroneously diagnosed with high blood pressure.
Immediate and overnight management
Follow the ABCDE approach!
See below for two short video demonstrating steps in the management of epistaxis.
FIRST AID
For patients without life-threatening bleeding, always start with gold-standard first aid (also known as Trotter's or Hippocratic method):
Sit with head forward over a bowl/sink
Pinch the fleshy part of the nose (nares) firmly, closing the nostrils
Hold the nose for 20 minutes without releasing the pressure
Suck on some ice or place ice packs on the forehead or nape of neck
Spit out any blood in the mouth: it is emetogenic
Keep as calm as possible
It is reasonable to try this in all patients, as this can avoid the insertion of unpleasant packs. Even torrentially bleeding patients will need first aid before help/equipment can be fetched.
Diagram A. An epistaxis management protocol in use at University Hospital Aintree, Liverpool. We have since increased the first aid time to 20 minutes. 'BD' - bed days.
Assess and resuscitate (if needed) in parallel.
SECOND-LINE MEASURES
If first aid measures are unsuccessful, attempt direct therapy. This includes cautery/rigid nasendoscopy (Basic Video/ Nasoendscopy Video) or applying a haemostatic matrix like Floseal.
Because of the risk of septal perforation, you should not cauterise:
Figure 1. Rapid Rhino inflatable nasal packs, 7.5cm (left) and 9cm double balloon (right).
repeatedly
large areas
both sides of the septum simultaneously.
If you cannot perform direct therapy because of equipment or expertise issues, insert a pack.
Packing is not a first line treatment for epistaxis - it is important to try all the above measures before nasal packing is used, unless the patient is bleeding very heavily. Bear in mind the drawbacks of packing:
mucosal trauma
pain and discomfort for the patient
obstruction of the nasal airway in COPD etc. patients
need for admission/increased length of stay
ASSOCIATED MANAGEMENT
Packed patients ought to have IV access.
Check the haemoglobin and consider a group and save. Clotting profile/INR is of no benefit unless the patient is on an anticoagulant, or has a history suggestive of coagulopathy (e.g. liver disease).
There is usually no benefit in stopping the warfarin or aspirin of any patients whose bleeding stops with simple measures or an anterior pack.
If epistaxis is torrential, ie not responsive to anterior packing or there is uncontrolled anticoagulation eg INR>10, then consider reversing anticoagulation.
Consider treating significant hypertension (SBP>200) but beware over-treatment, especially if the patient continues to bleed or requires a general anaesthetic.
RE-BLEEDING
Any fresh bleeding around the pack or down the patient's throat should prompt early re-assessment. Bear in mind that all patients with a nasal pack will have a certain amount of blood-stained mucus at the front of the nose - this does not mean they are bleeding.
While keeping one eye on your ABCDE approach, try:
ice
adding additional air if you are using Rapid Rhino or epistaxis balloon packs
placing a pack in the contralateral nostril to apply pressure from the other side
replacing the pack(s)
With every new intervention, apply pressure if appropriate and then wait to see whether it has worked (eg 10-15 minutes).
Be wary of nosebleeds not controlled after good bilateral packing (poorly placed packs with most of the balloon/tampon dangling over the mouth do not count). This does not necessarily mean you should take the patient straight to theatre, but you should be making plans to that effect, e.g. nil by mouth and involve the registrar.
If a patient is re-bleeding, and you are confident that you can place a good posterior/BIPP pack then it would be reasonable to do so, but still discuss the situation with the registrar. See below.
Further management
PATIENTS WITH NASAL PACKS
Most units in the UK admit packed patients, unless the packs are dissolvable and the patient is very well. Packs tend to stay in for 24-48 hours but shouldn't remain for much longer. Those with prolonged packing need oral antibiotics. All patients should have pain relief. Those with COPD or other respiratory conditions may need to sleep semi-upright or require supplementary oxygen.
DISCHARGING PATIENTS
Inflatable packs can be deflated for a while before removal, allowing them to be simply re-inflated if there is recurrent bleeding. Some units will routinely perform a speculum exam and/or nasendoscopy after removal of packs -- check with your senior. Any anterior bleeding point can either be cauterised and/or smothered in antiseptic cream (Naseptin is popular; check for a peanut allergy as it contains peanut oil).
Before discharge, patients can be advised:
not to blow, pick or otherwise traumatise their nose
to avoid piping hot food and drink for a day
to avoid strenuous activity or exercise for a day or two
to apply antiseptic cream or soft paraffin to both nostrils twice a day for two weeks, taking care not to push fingers or nozzles right up into the nose (sniffing it up is safer)
about first aid measures in case of a re-bleed
to re-attend A&E if they have a nosebleed lasting longer than 20 minutes
ENT UK About Epistaxis patient leaflet
OPERATING THEATRE
Consider urgent surgical arrest of haemorrhage (endoscopic sphenopalatine artery ligation in most cases) for patients:
bleeding despite effective packing
with further bleeding on pack removal after >24 hours
Involve the ENT middle grade/consultant sooner rather than later.
Plan:
NBM
Wide bore IV access x2
Keep packs in while waiting to go to theatre and continue first aid measures
Re-send full blood count and send G&S if not already done (clotting profile if indicated).
Actively replace fluid losses depending on cardiovascular status
Reverse clotting abnormalities with FFP, platelets etc.
Book case and discuss with the anaesthetist on-call, who can help with IV access and stabilisation if needed
Surgical management entails examination of the nasal cavity under GA. Point electrocautery can be performed, but endoscopic sphenopalatine artery ligation is generally the standard of care. Ethmoidal artery ligation can also be performed if required (uncommon). Failure to control bleeding may indicate angiography and embolisation by an interventional radiologist. External carotid artery ligation is an absolute last resort if this is not available.
VIDEOS
YouTube channel: @ENTSHOlearning