para>Infections
such as rhinitis, nasopharyngitis, and
sinusitis
Trauma,
inflicted (e.g., facial bone fractures) and
self-induced (e.g., nose picking)
Nasal
foreign body
Mucosal
atrophy from chronic steroid nasal sprays
Nasal
surgery
Local
irritants such as nasal sprays and cocaine
abuse
Dry nasal
mucosa
Allergic
and atrophic rhinitis
Hypertension and atherosclerotic cardiovascular
disease
Tumors and
polyps, benign or malignant
Nasal
defects, congenital or acquired
Bleeding
disorders, including hemophilia A, hemophilia B,
von Willebrand disease, thrombocytopenia, and
hypoprothrombinemia
Liver
disease
Renal
failure or uremia
Disseminated intravascular coagulation
Drug
induced, including nonsteroidal anti-inflammatory
drugs (especially salicylates), heparin, warfarin, thrombolytics, and
heavy metals
Anterior epistaxis usually can be
stopped by direct pressure, use of vasoconstrictors, simple cautery, and
packing. The first therapy is usually direct pressure, accomplished by
grasping the alae distally using the closed hand technique. This
provides firm compression and makes it easier for the patient to
maintain his or her grip. Time the nasal compression (5 to 10 minutes),
because patients usually underestimate the elapsed time. If direct
pressure is unsuccessful, apply a combined vasoconstrictive agent and
anesthetic (Table 95-2) using a spray bottle, atomizer, or pledget. A
moistened pledget provides better contact with the nasal mucosa while
also providing a local tamponade effect. ‚
Chemical cautery with silver nitrate sticks is effective treatment for
minor anterior nasal bleeding. First, control bleeding using
vasoconstrictors, direct pressure, or both, as it is difficult to
cauterize an actively bleeding area by chemical means alone. Electrical
and thermal cautery also may be used, but these are no better at
hemorrhage control than chemical cautery. Battery-powered, disposable,
heat cautery devices are difficult to control for the depth of cautery,
and significant injury can occur. ‚
Anterior nasal packing should be
considered when the previous methods fail after three attempts. Prepare
the nasal cavity with a combined vasoconstrictor and anesthetic agent
(Table 95-2). The nasal cavity is packed using strips of petrolatum-
or iodoform-impregnated gauze or an appropriate commercial device. If
nasal packing does not control isolated anterior bleeding, the anterior
pack should be reinserted to ensure proper placement. Leave anterior
packs in place for 48 hours. Ask the patient to report any fever or
recurrent bleeding and to return immediately if bleeding recurs or if
there is a sensation of blood trickling down the back of the throat. ‚
‚
TABLE 95-2. Vasoconstrictive and Anesthetic Agents for
Epistaxis View Large TABLE 95-2. Vasoconstrictive and Anesthetic Agents for
Epistaxis
-
0.5% " “1.0% " ‚phenylephrine (Neo-Synephrine)
mixed 2:1 with 4% " ‚lidocaine up to a total dosage of
4 mg/kg of lidocaine
-
0.05% oxymetozaline (Afrin) mixed with
4% " ‚lidocaine up to a total dosage of
4 mg/kg of lidocaine
-
0.25 mL of
1% (1:1,000 concentration) epinephrine mixed with 20 mL of
4% " ‚lidocaine up to a total dosage of
4 mg/kg of lidocaine
Commercial products have been
developed specifically to make the insertion of an anterior nasal pack
easier and more comfortable for the patient. Polyvinyl alcohol (PVA)
compressed foam sponges are made of dehydrated, spongelike material that
expands on contact with moisture. They may be more comfortable than a
balloon or gauze packing. It has been reported that the efficacy of this
device is comparable to other methods. Gelfoam packs also can be
used. ‚
Posterior packing may be required
for uncontrolled posterior bleeding. Posterior padding requires skill
and practice in the face of vigorous bleeding and is best performed in
emergency departments or hospital settings by physicians experienced in
such insertion. ‚
Equipment
- Handsfree light source
(can be an overhead surgical lamp, battery-operated headlamp, or
light held by an assistant) - Nasal speculum
- Cotton-tipped
applicators - Frazier tip suction tip
connected to continuous wall suction - Bayonnet forceps
- Material to tamponade the
site of bleeding, potentially including cotton pledgets, gelfoam
packs, and Merocel nasal sponges - Chemical cautery
agent - Topical antibiotic
ointment (e.g., Bacitracin or Neosporin) if using Merocel - Local medication for
vasoconstriction: either 0.5% to
1.0% " ‚phenylephrine (Neo-Synephrine) or 0.05% oxymetozaline (Afrin) nasal
spray - Local medication for
anesthesia: 4% " ‚lidocaine (up to
4 mg/kg total dose) - Personal protective
equipment including eyewear, mask, gown, and gloves
Indications
- Epistaxis that persists
despite adequate external pressure
Contraindications
- No current epistaxis
- Clotting abnormalities,
as aggressive packing may cause further bleeding (normalize
clotting mechanisms before removing nasal packs if possible) - Chronic obstructive
pulmonary disease (monitor for a drop in oxygen partial
pressure) - Trauma, especially facial
trauma (consider referral) - Known or suspected
cerebrospinal fluid leak - Drug abuse (e.g.,
cocaine) - Allergy to anesthetics or
vasoconstrictors
The Procedure
Step 1
Arterial anatomy of the nasal
septum. The Kiesselbach plexus is a complex anastomosis of
arterioles in the superficial region of the nasal mucosa on the
nasal septum. It is fed by the septal branches of the anterior
ethmoid (AE), posterior ethmoid (PE), sphenopalatine (S), superior
labial (SL), and greater palatine (GP) arteries. ‚
Step 1 View Original Step 1 View Original
Step 2
For acute, short-term
bleeding, apply pressure using the closed-hand method.
Vasoconstrictors may be used in conjunction with or independent of
directed pressure. Visualize the source of bleeding. Have the
patient blow his or her nose to remove all clots from the nasal
cavity and apply a vasoconstrictive agent (Table 2) in both nasal
cavities. Place the nasal speculum in the affected nare with your
left hand. With your right hand, apply a cotton-tipped applicator to
the medial wall of the affected nasal cavity to remove clots and
look for active sources of bleeding. If bleeding is brisk, use the
Frazier tip suction to identify the site of bleeding. ‚
- PITFALL: Using two fingers to pinch the
nose (rather than the closed-hand method) makes it more
difficult to maintain a grip and keep adequate pressure on
the nose. - PITFALL: Bleeding will sometimes stop
after application of a vasoconstictive agent and subsequent
direct pressure. Wait at least 1 hour to make certain that
bleeding is controlled before putting away your equipment
and releasing the patient. - PITFALL: If you cannot visualize the site
of active bleeding by utilizing a nasal speculum and Frazier
tip suction, the bleeding is likely to be from a posterior
source and will require referral for posterior packing. In
this instance, the anterior nares will need to be packed by
utilizing Merocel as described below to slow down the
bleeding.
Step 2 View Original Step 2 View Original
Step 3
Chemical cautery or gelfoam
can be used if anterior epistaxis cannot be controlled with
vasoconstrictors, direct pressure, or both. Prepare the nasal cavity
with combined vasoconstrictor and anesthetic agent. After the
bleeding has stopped, dry the mucosa. Visualize the nasal cavity
using a nasal speculum to ensure proper gauze placement. Cauterize
the mucosa by touching the bleeding source with the tip of a silver nitrate stick for 10 to 15 seconds. Wipe
away any residual silver nitrate, and apply
antibiotic ointment if desired. Alternatively, gently place a piece
of gelfoam against the site of bleeding. The blood at the site will
adhere it to the surface of the nasal cavity. Carefully remove the
nasal speculum, and observe for any further bleeding. ‚
- PITFALL: Tissue necrosis may occur if both
sides of the septum are cauterized in the same session.
Step 3 View Original Step 3 View Original
Step 4
Next, apply gauze packing for
resistant anterior epistaxis. Using bayonet forceps, grasp one end
of a long strip of ‚ ¼-inch petrolatum, iodoform, or plain
gauze saturated with antibiotic ointment approximately 2 to 3 cm
from its end. Allow the end to double over so that the first pass
applies two layers of gauze. ‚
- PITFALL: Blind packing often results in
loose placement of the gauze and inadequate compression.
Inadequate packing is probably the most common cause of
treatment failure.
Step 4 View Original Step 4 View Original
Step 5
Insert the gauze through the
nasal speculum to the posterior limit of the floor of the nose. ‚
Step 5 View Original Step 5 View Original
Step 6
Withdraw the bayonet forceps
and nasal speculum. Reintroduce the nasal speculum on top of the
first layer of packing. Grasp another loop of gauze with the bayonet
forceps. Insert the gauze on top of the previous course using an
"accordion " ¯ technique so that part of each layer lies
anterior to the previous layer, preventing the gauze from falling
posteriorly into the nasopharynx. With each layer, use the forceps
to gently push the underlying strip downward. ‚
Step 6 View Original Step 6 View Original
Step 7
Repeat until the entire nasal
cavity is filled with layers of packing material. Observe the
patient for 30 minutes to make sure that adequate hemostasis has
been achieved. ‚
- PEARL: If the patient complains of choking
or a foreign body sensation in the back of the throat, look
for layers of an anterior nasal pack that have fallen
backward into the nasopharynx.
Step 7 View Original Step 7 View Original
Step 8
Alternatively, the PVA
compressed foam sponge may be used for anterior packing. PVA sponges
absorb blood and secretions from the nasal cavity, quickly expanding
to fill the cavity and tamponade the bleeding. Before insertion into
the bleeding nasal cavity, cover the sponge with antibiotic
ointment. Insert the sponge directly into the nare, placing it
posteriorly until resistance is felt. The proximal end of the sponge
should be flush with the nasal opening. Repeat this procedure for
the nonbleeding nasal cavity. Packing both sides prevents deviation
of the nasal septum, allowing the site of bleeding to be effectively
tamponaded by the packing. ‚
- PEARL: Drops of the vasoconstrictive agent
can be added to the PVA sponge if further expansion is
needed. - PEARL: Some sponges have a suture attached
to one end to facilitate future removal. The suture needs to
be left outside the nasal cavity and can be taped to the
cheek to keep it out of the way.
Step 8 View Original Step 8 View Original
Complications
- Continued bleeding
- Rebleeding with removal
of pledget/gelfoam or packing - Sinusitis
- Pain
- Toxic shock syndrome
(very rare) - Septal perforations (very
rare)
Pediatric Considerations
Anterior nosebleed management may be
managed as in the adult population. However, referral to a specialist
may be necessary for an uncooperative patient. ‚
Postprocedure Instructions
All patients with anterior epistaxis
should refrain from blowing the nose, avoid digital trauma, and use a
room humidifier. Saline nasal spray can be used to maintain the moisture
of nasal mucosal membranes. Patients with any type of nasal packing
should be prescribed both analgesic medication and prophylactic oral
antibiotics (amoxicillin-clavulanate,
fluoroquinolones) to prevent development of sinusitis and toxic shock
syndrome. Patients should be instructed to pinch their nares for 15 to
20 minutes prior to seeking medical care if bleeding recurs. If this
stops the bleeding, there is no immediate need for them to seek medical
attention for the epistaxis. The nasal packing should remain in place
for 24 to 48 hours, and the patient should come in for follow-up at that
time. ‚
If the bleeding is controlled,
instruct the patient not to manipulate the external nares or insert
foreign objects or fingers into the nasal cavity. Petrolatum or triple
antibiotic ointment may be applied to dry nasal mucosa with a
cotton-tipped applicator once or twice each day for several days. Have
patients avoid aspirin or nonsteroidal
anti-inflammatory drugs for 3 or 4 days. If bleeding recurs, the patient
should use home measures such as over-the-counter nasal sprays or direct
pressure for 5 to 10 minutes before returning for medical care. If
bleeding continues after repeating compression twice more, have the
patient seek immediate medical help. ‚
Coding Information and Supply Sources
‚
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 30901 Control nasal hemorrhage, anterior, simple (limited cautery
and nasal packing), any method $221.00 0 30903 Control nasal hemorrhage, anterior, complex (extensive
cautery and nasal packing), any method $327.00 0 CPT is a registered trademark of the American
Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008
MMH-SI 's copyrighted Physicians ' Fees and
Coding Guide.
Bibliography
1Chopra ‚ R.
Epistaxis: a review.
J R Soc
Health. 2000;120:31 " “33. ‚ [View Abstract] 2Frazee ‚ TA, Hauser ‚ MS.
Nonsurgical management of
epistaxis. J Oral Maxillofac
Surg. 2000;58:419 " “424. ‚ [View Abstract] 3Kotecha ‚ B, Fowler ‚ S, Harkness ‚ P,
et al. Management of epistaxis: a national
survey. Ann R Coll Surg
Engl. 1996;78:444 " “446. ‚ [View Abstract] 4Murthy ‚ P, Laing ‚ MR.
An unusual, severe adverse reaction to silver
nitrate cautery for epistaxis in an immunocompromised
patient.
Rhinology. 1996;34:186 " “187. ‚ [View Abstract] 5O 'Donnell ‚ M, Robertson ‚ G, McGarry ‚ GW.
A new bipolar diathermy probe for the
outpatient management of adult acute
epistaxis. Clin
Otolaryngol. 1999;24:537 " “541. ‚ [View Abstract] 6Pond ‚ F, Sizeland ‚ A.
Epistaxis: strategies for
management. Aust Fam
Physician. 2000;29:933 " “938. ‚ [View Abstract] 7Pope LER, Hobbs CGL.
Epistaxis: an update on current
management. Postgrad
Med J.
2005;81:309 " “314. ‚ [View Abstract] 8Pothula ‚ V, Alderson ‚ D.
Nothing new under the sun: the management of
epistaxis. J Laryngol
Otol. 1998;112:331 " “334. ‚ [View Abstract] 9Randall ‚ DA.
Epistaxis packing. Practical pointers for
nosebleed control. Postgrad
Med.
2006;119:77 " “82. ‚ [View Abstract] 10Randall ‚ DA, Freeman ‚ SB.
Management of anterior and posterior
epistaxis. Am Fam
Physician. 1991;43:2007 " “2014. ‚ [View Abstract] 11Sandoval ‚ C, Dong ‚ S, Visintainer ‚ P,
et al. Clinical and laboratory features of 178
children with recurrent epistaxis.
J Pediatr Hematol
Oncol. 2002;24:47 " “49. ‚ [View Abstract] 12Srinivasan ‚ V, Sherman ‚ IW, O 'Sullivan ‚ G.Surgical
management of intractable epistaxis: audit of
results. J Laryngol
Otol. 2000;114:697 " “700. ‚ [View Abstract] 13Swoboda ‚ TK.
Epistaxis. In: Meldon ‚ S, Ma ‚ OJ, Woolard ‚ R,
eds. Geriatric Emergency
Medicine. New
York:
McGraw-Hill;
2003:475 " “478. 14Tan ‚ LK, Calhoun ‚ KH.
Epistaxis.
Med Clin North
Am. 1999;83:43 " “56. ‚ [View Abstract] 152008 MAG Mutual Healthcare
Solutions,
Inc. 'sPhysicians '
Fee and Coding Guide. Duluth,
Georgia. MAG Mutual
Healthcare Solutions,
Inc.2007.