Epistaxis

Essentials

• Identify the site of bleeding and stop the bleeding.
  • The bleeding almost always originates in the anterior nasal septum.
  • Use a head lamp and a nasal speculum for the inspection.
• Identify the cause of bleeding by taking a good history http://www.dynamed.com/condition/epistaxis#CAUSES.
• Assess the need for further investigations.

Causes and diagnostic assessment

• Dry mucosa of the anterior part of the nasal cavity
• Injuries: nose fracture, hit in the nose, manipulation by finger
• Respiratory tract infections (particularly in children)
• Drugs predisposing to bleeding (aspirin, anticoagulants)
• Atherosclerosis and advanced age
• Rarely bleeding disorders, haematological diseases (that should be suspected if the patient has petecchiae or other bleedings, if the bleeding is very difficult to control or there is a history of bleeding disorder in the family)
• Excessive consumption of alcohol

Initial examination and treatment Interventions for Recurrent Idiopathic Epistaxis in Children

1. Clean the nose: remove tampons, use suction or ask the patient to blow out the clots.
2. Identify the site of bleeding by anterior rhinoscopy: from which side does the bleeding originate; is the site of bleeding the nasal septum (Locus Kiesselbach), the upper part of the nose or lower posterior part of the nose.
3. Constrict the mucous membranes with an anaesthetic-vasoconstrictor solution (lidocaine 40 mg/ml with adrenaline 1:1000 three drops per 5 ml of the solution). A ready lidocaine-adrenaline combination can also be used.
   • Soak a rich piece of cotton wool with the solution.
   • Place the piece on the supposed site of bleeding whereafter the nostrils are pressed together for at least 15 minutes.
4. If the bleeding site is now visible as a small pinhead-like clot or as superficial feeding vessels, cauterize http://www.dynamed.com/condition/epistaxis#CAUTERY it either with a pearl of silver nitrate (e.g. Avoca^® , Bray Health & Leisure) (video Cauterization of Bleeding Vessel in Epistaxis), or alternatively by electrocauterization (bi- or monopolar mode).
   • Apply the silver nitrate pearl on the site of bleeding for a few seconds so that a pale coagulated area 2-4 mm in diameter appears. After the silver nitrate application, neutralize the treated area by pressing it a few times with a cotton wool ball soaked in 0.9% saline. Finally the nose is gently dried by pressing it with dry cotton wool.
5. If the bleeding site cannot be seen and the bleeding has stopped, and if the bleeding has not been profuse, insertion of a tampon is not necessary. Provide the patient with written instructions on what to do if the bleeding recurs.
   • If the bleeding continues or it was profuse insert an anterior tampon http://www.dynamed.com/condition/epistaxis#ANTERIOR_NASAL_CAVITY_PACKING by using either a ready strip of petrolatum gauze, a self-expanding tampon (e.g. Merocel^® , Ivalon^® ) or a balloon tampon filled with saline or air (e.g. Rapid Rhino^® ). If a ready-made tampon is not available it can also be self-prepared from a long saline-soaked gauze strip that is lubricated with white vaseline.
     • Apply lidocaine-adrenaline solution locally (see above).
     • Tamponate the nostril by filling the posterior and upper parts first under visual control using a nasal speculum. Finally, fill the anterior part of the nose.
     • Leave the tampon in place for at least one day (maximum 3 days). If the bleeding restarts after the tampon has been removed, the patient should preferably be referred to a care unit where the nose can be examined through endoscopy.
   • Alternatively, pieces of gelatin (e.g. Spongostan^® ) can be inserted into the nostril. These may be sufficient to stop scanty bleeding. The gelatin pieces are resolved or expelled spontaneously so no removal is required.
   • A patient in good condition does not need hospitalization after anterior tamponation.
6. Posterior tamponationhttp://www.dynamed.com/condition/epistaxis#POSTERIOR_NASAL_CAVITY_PACKING should be performed if the bleeding does not stop with anterior tamponation.
   • Apply lidocaine-adrenaline solution (see above).
   • Traditional gauze tampons are nowadays used primarily in specialized care for exceptionally heavy bleeding. Usually, a ready-made tampon with two separate air- or saline-fillable balloons is used (picture ). A Foley urine catheter can also be used as first aid.
     • Insert the empty tampon into the nose by its whole length. Always push the tampon horizontally along the bottom of the nasal meatus.
     • Fill the posterior balloon with a specified amount of air or saline (usually about 10 ml) and pull it into the choanal opening. Thereafter fill the anterior balloon with a sufficient amount of air or saline (usually 15-20 ml) so that it fills up the nostril. Make sure that the tampon does not chafe or press the edge of the nostril.
     • If a Foley catheter is used, insert also an anterior gauze tampon and fasten the catether into it.
     • The patient must always be treated in a hospital. The posterior tampon should be removed as soon as possible by endoscopic clipping or cauterization of the sphenopalatine artery. If endoscopic closure is not possible, the tampon is left in place for 2-4 days.
     • E.g. cephalexin is given as antimicrobial prophylaxis for the duration of the tamponation http://www.dynamed.com/condition/epistaxis#OTHER_MEDICATIONS.
7. Determine blood haemoglobin if bleeding has been profuse.

Epistaxis in a child

• Do not insert a tampon in a child's nose. If treatment with silver nitrate pearl is not sufficient, refer the child to specialized care.
• The aetiology of bleeding from the anterior part of the nose is often colonization by staphylococci.
• Further treatment should always include mupirocin nasal ointment in the mornings and evenings for one week.
• In recurring epistaxis with multiple bleeding sites, remember the possibility of a blood coagulation disorder, which often cause epistaxis as their first symptom.

Home instructions for patients

1. Calm down.
2. Sit leaning forward so that the blood does not flow down the throat.
3. Blow out clots from your nose and press the nostrils together at the front part of the nose for at least 15 minutes.
4. An ice cube in the mouth may help in stopping the bleeding.
5. If the bleeding has not stopped after 15 minutes of pressure it is best to contact a doctor. During the transportation you should sit leaning forward, not lie down.

Indications for specialist consultation