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 and mucosal breakage due to blowing one's nose (particularly in children)
• Drugs predisposing to bleeding (aspirin, anticoagulants)
• Atherosclerosis and advanced age
• Hypertension
• 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) Assessment and Treatment of a Patient with Bleeding Diathesis
• Excessive consumption of alcohol

Initial examination and treatment Interventions for Recurrent Idiopathic Epistaxis in Children

1. Clean the nose: remove any 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 anterior nasal septum (Locus Kiesselbach), the upper part of the nose or lower posterior part of the nose.
3. Constrict and anaesthetize the mucous membranes with a lidocaine-adrenaline solution.
   • 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 not visible, but the bleeding has stopped and it was not profuse, the nose needs no tamponade. Instead, provide the patient with aftercare instructions.
5. 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 Treatment of Epistaxis with Silver Nitrate), or alternatively by electrocauterization (bi- or monopolar mode).
     • The pearl of silver nitrate is pressed on the bleeding site for a few seconds to create a pale coagulation spot 2-4 mm in diameter. After the application of silver nitrate, the treated mucosal area is neutralised by pressing it a few times with a piece of cotton wool soaked with saline solution. Finally, the nose is dried by carefully pressing with a dry cotton swab.
   • The bleeding can also be stopped by compressing the anterior part of the nose with a piece of cotton swab moistened with tranexamic acid solution.
   • Alternatively, moistened pieces of gelatin (Spongostan^® ) can be inserted into the nostril, which may stop minor bleeding. The gelatin pieces are expelled or resolved spontaneously so no removal is required.
     • Moistening with tranexamic acid solution or xylometazoline or adrenalin will enhance the cessation of bleeding.
6. If the bleeding continues or was profuse, an anterior tamponade should be performed, usually either with a self-expanding tampon (e.g. Merocel^® , Ivalon^® ) or a balloon tampon filled with saline or air (e.g. Rapid Rhino^® ).
   • Apply lidocaine-adrenaline solution (see above).
   • 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.
   • The tampon is unpleasant for the patient and the bleeding site can nearly always be found and treated with nasal endoscopy. A patient with tamponade can also be referred to a ENT unit for localization and treatment of the bleeding site.
   • A patient in good condition does not need hospitalization after anterior tamponation.
7. Posterior tamponationhttp://www.dynamed.com/condition/epistaxis#POSTERIOR_NASAL_CAVITY_PACKING should be performed if the bleeding does not stop with anterior tamponation. The procedure is rarely needed and is usually performed in specialized care.
   • Apply lidocaine-adrenaline solution (see above).
   • A (commercial) ready-made balloon tampon intended for stopping nasal bleeding is inserted empty through the nostril by its whole length (see detailed instructions of the product). 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.
     • A patient with posterior tamponade should be hospitalized.
8. Determine blood haemoglobin if bleeding has been profuse.
9. Whatever the treatment method, it is a good idea to moisten the nasal mucous membranes at home after the treatment, either with an oil solution or a mixture of oil and water.

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. Keep calm.
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 referring the patient to an ENT specialist