Mastering Minor Care: Management of Epistaxis

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You’re working a minor care shift when you notice your next patient has a chief complaint of epistaxis. What’s your approach? What do you look out for to make sure you don’t fall prey to triage bias? As you walk into the room, you start assessing the acuity of the patient. This begins by evaluating the patient’s airway, breathing, and circulation. If the patient has such a significant nosebleed that you’re concerned about their ability to protect their airway or hemodynamic instability, they should be moved to the critical care area of the emergency department immediately.

Causes

FiG.1 KIesselBach’s PLexus and Sphenopalatine ARtery in relation to major nasal vessels. [9]

FiG.1 KIesselBach’s PLexus and Sphenopalatine ARtery in relation to major nasal vessels. [9]

Let’s say in this circumstance that you’ve evaluated the patient’s ABCs and vital signs and determined that they are appropriately triaged. As you obtain the history, try to determine what caused the epistaxis. Common causes include digital trauma (e.g. nose picking), lack of humidity, sinusitis, cocaine use, chronic vasoconstrictor use, and malignancy. Systemic illnesses that can cause epistaxis include renal insufficiency, alcohol abuse, hypertension, and coagulopathy (inherited or drug-induced).

The next branch point will be trying to ascertain whether the patient has an anterior nosebleed or a posterior one. While anterior bleeds are overwhelmingly more common, approximately 90%, it is important to make sure you don’t miss a posterior bleed which is associated with significant morbidity.[1] The most common location for anterior bleeds is Kiesselbach plexus whereas the sphenopalatine artery (Fig 1) is the source for most posterior bleeds. [1]

Approach and Management

When examining the nose, it is important to have appropriate personal protective equipment to prevent coming into direct contact with the patient’s blood. This includes gloves, facemask, and protective eyewear. If using a nasal speculum to examine the nostril, it should be inserted in a cephalad-to-caudad manner to prevent damaging the nasal septum. The use of a Frazier Tip suction device and a headlamp can assist obtaining a view of the source of bleeding in the affected naris. [2]

Management of Uncomplicated Epistaxis

  1. Ask the patient to blow their nose to disrupt pre-formed clot

  2. Spray oxymetazoline (Afrin) in the suspected naris to induce vasoconstriction. Depending on your institution, 4% cocaine hydrochloride solution (Numbrino) may also be available for use which can also be utilized in lieu of Afrin to assist with vasoconstriction.

  3. Ask patient to hold firm pressure over the fleshy part (alae) of their nose for 10-15 minutes to tamponade the bleed. (Commonly patient apply pressure over the bony part which does not help with hemostasis). In those more prone to rebleed (e.g. coagulopathic patients), it may be reasonable to attempt direct cauterization as a first intervention as described in the management of complicated epistaxis described in the next section.

  4. Observe for resolution of epistaxis; if resolved after 60 minutes of observation, discharge with recommendation to sleep in a humidified environment, use saline nasal sprays, avoid digital trauma, and follow up with ENT.

Management of Complicated Epistaxis

Fig 2. Bilateral Anterior Packing for Uncontrolled Epistaxis [10]

Fig 2. Bilateral Anterior Packing for Uncontrolled Epistaxis [10]

If the steps above fails to control the bleeding, the next approach for cessation of bleeding is a variety of options as listed below. It is often helpful for patient comfort to administer topical lidocaine to the affected naris before proceeding with the following interventions.

  1. If you are able to visualize anterior bleeding, you can chemically cauterize the area with silver nitrate. There is moderate evidence demonstrating that chemical cautery is more effective than non-dissolvable anterior packing [3]. It is extremely important to avoid cauterizing both nares as it can lead to iatrogenic septal perforation. If bleeding ceases for 30-60 minutes, patient can be discharged with ENT follow-up.

  2. If cautery is unsuccessful, you can attempt packing the nose with a multitude of devices. One of these options include a tranexamic (TXA) soaked pledget followed by direct pressure. In a head to head study comparing TXA versus anterior packing with lidocaine/epinephrine alone, patients in the TXA group were more than twice as likely to experience cessation in bleeding with 10 minutes [4]. Furthermore, a recent Cochrane review demonstrated moderate-quality evidence supporting the use of topical TXA in epistaxis [5]. If bleeding ceases after 10 minutes of TXA pledget application, and the pledget is able to remove with no further bleeding after 30-60 minutes, patient can be discharged with outpatient follow up with ENT.

  3. If TXA or Cautery is unsuccessful, you can attempt to pack the anterior naris with an anterior packing or balloon device such as the Rapid Rhino or Merocel, which both have been demonstrated a high rate of success in cessation of anterior bleeds [6][7]. Although usually successful, these interventions tend to be a last resort due to the discomfort experienced by patients. Patients that receive anterior packing must follow up with ENT within 2-3 days and receive anti-Staphylococcus prophylaxis (Keflex/Augmentin) to prevent toxic shock syndrome. A literature discussion in regards to packing by Dr. Sanjay Shewakremani can be found here.

  4. If none of the above methods control the bleeding, the patient could either have severe anterior epistaxis or posterior epistaxis. Bilateral anterior packing (Fig 2) or a posterior nasal packing can be attempted in the emergency department, but the patient will ultimately require an otolaryngology consult or transfer to a hospital that has otolaryngology capabilities. Patient will require admission for observation in a monitored setting given the high morbidity of uncontrolled epistaxis and potential for airway compromise [8]. University of Cincinnati’s complete epistaxis algorithm can be found here.

Summary

  • Obtain an accurate history and vitals on all epistaxis patients on presentation. Any unstable patient should be treated for potential hemorrhagic shock and have airway monitored.

  • Uncomplicated epistaxis can typically be treated with direct pressure over the alae for 10-15 minutes or by direct cautery and subsequent observation to assess for rebleeding

  • Complicated epistaxis (uncontrolled by pressure alone) can be treated via TXA soaked pledgets, cautery, and anterior packing devices such as the Rapid Rhino and Merocet. If a patient has anterior packing placed, the patient will require ENT follow-up within 48-72 hours for packing removal and should also be placed on prophylactic antibiotics to prevent toxic shock syndrome.

  • Uncontrolled anterior bleeding or posterior bleeding requires an ENT consult and admission to observe for potential complications.

AUTHORed by HAMZA IJAZ, MD

Dr. Ijaz is a PGY-1 in Emergency Medicine at the University of Cincinnati

POST AND PEER EDITING by SHAN MODI, MD

Dr. Modi is a PGY-3 in Emergency Medicine at the University of Cincinnati and Resident Editor of the ‘Minor Care Series’

FACULTY EDITing by EDMOND HOOKER, MD, DRPH

Dr. Hooker is an Assistant Professor of Emergency Medicine at the University of Cincinnati and Faculty Editor of the ‘Minor Care Series’

References

  1. McGinnis HD. Nose and Sinuses. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e New York, NY: McGraw-Hill.

  2. Riviello RJ. Otolaryngologic Procedures. In: Chanmugam AS, Chudnofsky CR, DeBlieux PMC, Mattu A, Swadron SP, Winters ME. eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, 7e Philadelphia, PA: Elsevier.

  3. Shargorodsky J, Bleier B, Holbrook E, et al. Outcomes analysis in epistaxis management: development of a therapeutic algorithm. Otolaryngol Head Neck Surg. 2013;149(3):390-398.

  4. Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013;31(9):1389-92.

  5. Joseph J, Martinez-Devesa P, Bellorini J, Burton MJ. Tranexamic acid for patients with nasal haemorrhage (epistaxis). Cochrane Database Syst. Review. 2018. doi 10.1002/14651858.CD004328.pub3.

  6. Badran K, Malik T, Belloso A, Timms M. Randomized controlled trial comparing Merocel and RapidRhino packing in the management of anterior epistaxis. Clin Otolaryngol. 2005;30(4):333-337.

  7. Moumoulidis I, Draper MR, Patel H, Jani P, Price T. A prospective randomised controlled trial comparing Merocel and Rapid Rhino nasal tampons in the treatment of epistaxis. Eur Arch Otorhinolaryngol. 2006;263(8):719-722.

  8. Supriya M, Shakeel M, Veitch D, Ah-See K. Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome. J Laryngol Otol. 2010;124(7):744-749.

  9. Locus Kiesselbachi. In: Wikipedia. ; 2017. https://de.wikipedia.org/w/index.php?title=Locus_Kiesselbachi&oldid=162305716. Accessed March 29, 2020.

  10. Epistaxis Packing after a Posterior Episode.; 2011. https://commons.wikimedia.org/wiki/File:Epistaxis_packing.jpg. Accessed March 29, 2020.