para>More likely anterior, idiopathic, and recurrent á
Geriatric Considerations
More likely to be posterior bleed
á
TREATMENT
- Most cases are managed as outpatient (1)[B].
- Home use-Nosebleed QR: a nonprescription powder of hydrophilic polymer with potassium salt; induces scab formation
- Patient applies direct pressure by pinching the lower part of the nose (nasal ala) for 5 to 20 minutes without a break. This will stop active bleeding in most patients.
- An ice pack placed over the dorsum of the nose may help with hemostasis.
- Inspect the nasal septum for the bleeding site.
GENERAL MEASURES
Resuscitation, as indicated. Use universal "ABC"Ł approach. á
MEDICATION
First Line
- If general measures fail, affected naris may be sprayed with topical vasoconstrictor, such as:
- Phenylephrine: 0.5-1%
- Oxymetazoline: 0.05%
- Epinephrine: 1:1,000
- Cocaine: 4%
Second Line
- Chemical (silver nitrate) or electrical cautery
- Nasal packing: ribbon gauze, nasal tampons, nasal balloon catheter
- For intractable/refractory: Consider surgical ligation, endoscopic ligation/cautery, endovascular embolization.
ISSUES FOR REFERRAL
- Posterior bleeding frequently requires an otolaryngology consultation.
- Anterior bleeding that fails conservative measures, packing, and cauterization
- Recurrent episodes
- Patients with HHT should establish care with ENT early.
ADDITIONAL THERAPIES
- Nasal packing: either with ribbon gauze or preformed nasal tampons. Systemic prophylactic antibiotics are unnecessary in the majority of patients with nasal packs; topical antibiotics may be as effective and cheaper (2)[B].
- FloSeal: A biodegradable hemostatic sealant (a thrombin-type gel) in one study is more effective and better tolerated than packing (3)[B].
- If an actively bleeding anterior septal site is visualized, this may be treated with gentle and specific silver nitrate cautery for ~10 seconds for definitive treatment. 75% silver nitrate is preferred. Apply in a spiral fashion, starting around the bleeding vessel, moving inward.
- Limit cautery (silver nitrate) to one side of septum, or wait 4 to 6 weeks in between treatments to reduce risk of perforation.
- Posterior: posterior packing or tamponade with balloon devices (Foley catheter has been used). Inpatient monitoring is generally required.
- Recurrent epistaxis: Cochrane review in children shows no difference in effectiveness between antiseptic nasal cream, petroleum jelly, silver nitrate cautery, or no treatment (4)[A].
- Silver nitrate cautery followed by 4 weeks of antiseptic cream may be better than antiseptic cream alone (5)[B].
SURGERY/OTHER PROCEDURES
- Packing
- Layering of Vaseline ribbon gauze (1/2 inch)
- For gauze packing, be certain that both ends of the ribbon gauze protrude from the nostril.
- Packing is layered from the floor upward.
- Secure packing with gauze across the outside of the nostril.
- Nasal tampon may be used after lubricating the tip with KY Jelly or antibiotic cream or ointment.
- Additional saline may be needed to expand the tampon if the bleeding has slowed.
- Merocel and Rapid Rhino packs are easier to use than gauze packing and are usually well tolerated.
- Posterior bleed
- In the emergent setting, this may be attempted utilizing a Foley catheter or a specific posterior packing balloon.
- With both methods, the tubing is introduced through the nose similar to the passage of a nasogastric tube. Once it reaches the posterior oral pharynx, the balloon is inflated and the tubing is pulled back outward to tamponade the posterior bleeding source.
- If using a Foley catheter (10 to 14F catheter), the balloon can be inflated with 10 mL of saline.
- Traction is maintained with an umbilical cord clamp with adequate padding between the clip and the nose to avoid injury.
INPATIENT CONSIDERATIONS
Consider hospitalization for elderly or for patients with posterior bleeding or coagulopathy. May also consider if significant comorbidities á
Admission Criteria/Initial Stabilization
- Posterior bleed
- Hemodynamic changes
- Clotting dysfunction
- Universal "airway/breathing/circulation"Ł (ABC) approach. Stop blood loss.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- When significant blood loss, hemodynamic monitoring
- 24-Hour minimum of packing in place; some authors recommend 3 to 5 days. The latter recommendation carries the risk of mucosal injury and toxic shock syndrome. The former has the risk of rebleed, which usually occurs between 24 and 48 hours.
PATIENT EDUCATION
- Demonstrate proper pinching pressure techniques.
- Avoidance of trauma or irritants is key.
- Management of systemic illness and proper use of medication
PROGNOSIS
- Most are self-limited.
- Good results with proper treatment
COMPLICATIONS
- Septal perforation
- Pressure-induced tissue necrosis of the nasal mucosa
- Toxic shock syndrome with packing
- Arrhythmias triggered by packing (particularly posterior)
REFERENCES
11 Melia áL, McGarry áGW. Epistaxis: update on management. Curr Opin Otolaryngol Head Neck Surg. 2011;19(1):30-35.22 Biggs áTC, Nightingale áK, Patel áNN, et al. Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Ann R Coll Surg Engl. 2013;95(1):40-42.33 Mathiasen áRA, Cruz áRM. Prospective, randomized, controlled clinical trial of a novel matrix hemostatic sealant in patients with acute anterior epistaxis. Laryngoscope. 2005;115(2):899-902.44 Qureishi áA, Burton áMJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2012;(9):CD004461.55 Calder áN, Kang áS, Fraser áL, et al. A double-blind randomized controlled trial of management of recurrent nosebleeds in children. Otolaryngol Head Neck Surg. 2009;140(5):670-674.
ADDITIONAL READING
- Manes áRP. Evaluating and managing the patient with nosebleeds. Med Clin North Am. 2010;94(5):903-912.
- Schlosser áRJ. Clinical practice. Epistaxis. N Engl J Med. 2009;360(8):784-789.
CODES
ICD10
R04.0 Epistaxis á
ICD9
784.7 Epistaxis á
SNOMED
- 12441001 Epistaxis (disorder)
- 232354002 Anterior epistaxis
- 232355001 Posterior epistaxis
- 232356000 Traumatic epistaxis
CLINICAL PEARLS
- Most episodes are anterior in etiology and respond to timed pressure over the anterior nares for 5 to 20 minutes.
- Most are idiopathic or as a result of nose picking.
- Posterior nosebleeds can be asymptomatic or present with nausea, hematemesis, or heme-positive stool.
- Consider evaluation for neoplasm if recurrent unilateral episodes.