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).
  • 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! Download the podcast.

 

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.

 

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 (link to follow) 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).

 

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)

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.

 

Page last reviewed: 26 July 2018