Author:

Richard E.Wolfe

Signs and Symptoms

Essential Workup

• Assess stability: Airway compromise, hypovolemia
• Determine source (anterior vs. posterior)
• Consider underlying coagulopathy

Diagnostic Tests & Interpretation

Differential Diagnosis

• Hematemesis
• Hemoptysis

Prehospital

• Stable patients: Patient should bend forward at the waist; pinch nares closed, and spit out blood rather than swallow it
• Unstable patients:
  • Intubation, if airway is compromised
  • IV access
  • Crystalloid resuscitation, if signs of hypovolemia

Initial Stabilization/Therapy

• Secure the airway in patients who are unconscious, have major facial trauma, or are otherwise at risk of obstruction or aspiration
• Treat hypotension with crystalloids and blood products, if necessary, and ensure adequate IV access
• Nonconsensus on the value of treating hypertension

ED Treatment/Procedures

• Universal precautions against blood/fluid contamination
• Anterior source:
  • Have patient apply direct pressure by pinching nares closed for 15 min
  • Have patient blow the nose to expel the clot prior to the exam
  • If bleeding persists, use bayonet forceps to place cotton pledgets soaked in vasoconstricting and anesthetic agents into affected nares
  • If view is obstructed by blood, have patient blow nose, or clear blood from view with irrigation and suction
  • Visualize source of bleeding with a nasal speculum
  • Cauterize limited area with silver nitrate or electrocautery:
    • Ensure septum is dry before cauterization through prior application of a cotton gauze soaked with a vasoconstrictor and topical anesthetic
    • After apply antibiotic ointment or petroleum jelly
  • Consider Gelfoam or Surgicel packing over cauterized site
• Anterior nasal packing:
  • Indicated when cautery has failed to control bleeding
  • Associated with significant discomfort and infectious risk of sinusitis and toxic shock
  • Anterior nasal balloon:
    • Check the integrity of the balloons before insertion
    • Cover with water-based lubricant or viscous lidocaine
    • Insert the device and inflate it slowly to avoid discomfort
    • Use saline for the inflation if the balloon is to remain in place > a few hours
  • Preformed nasal tampons:
    • Adequate anesthesia of the nasal passage should be ensured before placing the tampon
    • Lubricate the tip of the sponge tampon with antibiotic ointment
    • Insert it at a 45-degree angle ∼1-2 cm into the nasal cavity
    • Rotate the long axis of the tampon into a horizontal plane and push it firmly back into the nasal cavity
    • If the pack does not fully expand from the blood, then use saline to complete the expansion
    • Secure the drawstring to the cheek
  • Petroleum jelly-impregnated gauze:
    • Add an antibiotic ointment to the gauze
    • Ensure that a free end remains outside the nose
    • Place the gauze as far back as possible, starting on the floor of the nose
    • Layer gauze in an accordion fashion
    • Repeat while securing the placed gauze with the speculum until the nose is fully packed
  • After anterior packing, persistent new bleeding may be a sign of inadequate packing or posterior source
  • Bilateral may be required to achieve adequate pressure to control bleeding if a single side packing fails
  • Always treat patients with nasal packing with antibiotics to prevent sinusitis and prevent or limit Staphylococcus aureus infections that can lead to toxic shock syndrome (TSS)
• Posterior source:
  • Early endoscopic visualization and cautery of bleeding source may prevent need for posterior packing and admission
  • Posterior packing may be accomplished with commercially available devices such as Nasostat or Epistat
  • If commercial packs are unavailable, a Foley catheter may be directed into posterior nasopharynx until the tip visible in mouth. The balloon is then inflated and the catheter retracted until the balloon is lodged in the posterior nasopharynx. The catheter is then held in place by umbilical clamp
  • Posterior pack should not be left in >3 d due to infectious risk. Patient should be admitted and on telemetry while pack in place due to risk of vagal response
• Complications of packing:
  • Pressure necrosis of posterior oropharynx (do not overfill balloon)
  • Nasal trauma
  • Septal perforation
  • Sinusitis
  • TSS
  • Vagal response with reflex bradycardia
  • Aspiration
  • Hypoxia
• If the patient in on anticoagulants or has a bleeding disorder, use of reversal agents or blood products should be considered on a case by case basis
• For epistaxis not amenable to control by packing, ORL consultation to consider the following options:
  • Surgical ligation of vessels
  • Septal surgery
  • Endoscopic electrocautery
  • Angiographic embolization

Medication

• Vasoactive solutions:
  • 4% cocaine
  • 1:1 mixture of 2% tetracaine and epinephrine (1:1,000)
  • 1:1 mixture of oxymetazoline 0.05% (Afrin) and lidocaine solution 4%
  • Phenylephrine (0.5-1%)
• Antibiotics: For use while packing in place
  • Amoxicillin-clavulanate potassium: 250 mg PO q8h
  • Cephalexin: 250 mg PO q6h
  • Clindamycin: 150 mg PO q6h
  • Trimethoprim-sulfamethoxazole: 160/800 mg PO q12h

Disposition

Follow-up Recommendations

• Return to ED for bleeding not controlled by pressure, fever, difficulty breathing, or vomiting
• Avoid any nose blowing for 12 hr after the bleeding stops
• Avoid nose picking or putting anything into the nose
• If the bleeding starts again, sit up and lean forward, pinch the soft part of the nose tightly for 10 min without letting go
• Avoid lifting heavy objects or doing too much work right away
• If there is no packing in the nose, put a small amount of petroleum jelly or antibiotic ointment inside the nostril 2 times a day for 4-5 d
• Use a humidifier or vaporizer at home

• KasperekZA, PollockGF. Epistaxis: An overview . Emerg Med Clin N Am. 2013;31:443-454.
• McleodRW, PriceA, WilliamsRJ, et al. Intranasal cautery for the management of adult epistaxis: Systematic review . J Laryngol Otol. 2017;131(12):1056-1064.
• NewtonE, LassoA, PetrcichW, et al. An outcome analysis of anterior epistaxis management in the emergency department . Otolaryngol Head Neck Surg. 2016;45:24.

The authors gratefully acknowledge Christopher McCarthy for his contribution to the previous edition of this chapter.

ICD9

784.7 Epistaxis

ICD10

R04.0 Epistaxis

SNOMED

• 12441001 Epistaxis (disorder)

• 232354002 Anterior epistaxis

• 232355001 Posterior epistaxis

• 232356000 Traumatic epistaxis

• 232357009 Post-surgical epistaxis (disorder)