- Patients on full dose anticoagulants eg warfarin or heparin infusion
- Patients who continue to bleed despite two good attempts at nasal packing
- Trauma patients - internal anatomy may be deformed
When to involve the ENT Registrar
- Patients who continue to bleed despite two good attempts at packing
Who to admit
- Packed patients
- Older, frailer patients who may need help at home or live alone, especially if it is late at night
- Suitable for next emergency clinic: patients with small volume, <20 minute bleeds
- NB Those bleeding torrentially OR for more than 20 minutes despite first aid measures should be directed to A&E and NOT to the ward treatment room
Assessment and recognition
Try to establish where the bleeding is coming from.
- The vast majority of bleeding is anterior from Little's area of the septum (this 'trumps' everything below about posterior bleeds)
- Initially comes out of one nostril only
- Predominantly comes out of the front but some can trickle into the throat, especially on tilting the head backwards, applying first aid or when the nose is full of clot
- 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, like fractured neck of femur, 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, iaotrogenic drying (nasal oxygen), anticoagulation (warfarin) and minor trauma (nose blowing or picking) are enough to precipitate bleeding.
Traumatic epistaxis is usually due to bleeding from the anterior ethmoid arteries and usually settles soon after the initial blow. Intractable traumatic epistaxis is rare and may need urgent surgical ligation.
Rarer causes include neoplasm, coagulopathy and hereditary haemorrhagic telangiectasia (HHT).
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. For others, pre-existing high blood pressure may prolong bleeding.
Immediate and overnight management
Follow the ABCDE approach! Download the podcast.
For those not in extremis, use gold-standard first aid (also known as Trotter's or Hippocratic method):
- Sit with head forward over a basin/sink
- Pinch the fleshy part of the nose (nares) firmly
- Hold the nose for 20 minutes without peeking
- 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.
Do not accept less than gold-standard first aid: not everyone can hold their own nose firmly for 20 minutes without peeking/a break. Assess and resuscitate (if needed) in parallel.
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 making things worse, you should not cauterise:
- large areas
- both sides of the septum simultaneously.
If you cannot perform direct therapy because of equipment or expertise issues, insert a pack.
Many units try to avoid packing unless first aid measures have failed. Packing is not a first line treatment for epistaxis. It is generally effective but bear in mind the drawbacks:
- mucosal trauma
- pain and discomfort for the patient
- obstruction of the nasal airway in COPD etc. patients
- need for admission/increased length of stay
Packed patients ought to have IV access.
Check the haemoglobin and consider a clotting screen/INR and group and save.
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.
Any bleeding around the pack should prompt early re-assessment. While keeping one eye on your ABCDE approach, you could try:
- adding 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 two good packs (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 eg nil by mouth and involve the registrar.
If you are confident that you can place a good posterior/BIPP pack then it would be reasonable to do so and still discuss the situation with the registrar. See below.
PATIENTS WITH NASAL PACKS
Most units in the UK admit packed patients. Packs tend to stay in for 24-48 hours but shouldn't remain for much longer. Those with posterior packs need oral antibiotics and may need extra pain relief or light sedation. Those with COPD or other respiratory conditions may need to sleep semi-upright or require supplementary oxygen.
Packs can be deflated for a while before removal. Some units will routinely perform a speculum exam and/or nasendoscopy after removal of packs. Any anterior bleeding point can either be cauterised or smothered in antiseptic cream (Naseptin is popular; check for a peanut allergy as it contains peanut oil).
There is, however, some evidence that such a one-size-fits-all approach can be detrimental. Cautery and nasendoscopy requires cleaning of the nasal mucosa, which may traumatise it and lead to further bleeding and readmission. Furthermore, the incidence of sinonasal malignancy in patients admitted for epistaxis is low: you would have to endoscope thousands of epistaxis patients to pick up one additional malignancy.
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 good)
- 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
Consider urgent surgical arrest of haemorrhage for those:
- bleeding despite two or more good nasal packs
- with torrential bleeding
Involve the ENT middle grade/consultant sooner rather than later.
- Wide bore IV access x2
- Keep ineffective packs in while waiting to go to theatre and continue first aid measures
- Re-send full blood count, clotting and send G&S if not already done
- Actively replace fluid losses depending on cardiovascular status
- Reverse clotting abnormalities with FFP, platelets etc.
- Book and discuss with the anaesthetist; consent if you know how
Procedure: examination of nose under anaesthetic and surgical arrest of epistaxis.
This involves a general anaesthetic, removal of packs, instillation of vasoconstricting agents into nose, suction of clots under endoscopic guidance and identification of bleeding point(s). Frequently, diathermy and/or application of a haemostatic agent suffice. Sometimes it is necessary to ligate blood vessels like the sphenopalatine or even the external carotid.
Page last reviewed: 23 September 2016