0Epistaxis
Epistaxis is split into anterior and posterior bleeds, whereby the former often have a visible source of bleeding and usually occurs due to an insult to the network of capillaries that form Kiesselbach’s Plexus.
Posterior haemorrhages, on the other hand, tend to be more profuse and originate from deeper structures.
They occur more frequently in older patients and confer a higher risk of aspiration and airway compromise.
CAUSES
While most cases of epistaxis tend to be benign and self-limiting,
they may be an indicator of serious pathology.
The most common cause is trauma to the nose- this can range from the insertion of foreign bodies, nose picking and nose blowing.
Bleeding can also indicate platelet function disorders such as thrombocytopenia, splenomegaly, leukaemia, Waldenstrom’s macroglobulinaemia and ITP. As these tend to be congenital, they often present earlier in life.
In adolescent males, juvenile angiofibroma is a beginning tumour that may bleed as it is highly vascularised.
If the nasal septum looks abraded or atrophied, inquire about drug use. This is because inhaled cocaine is a potent vasoconstrictor, and repeated use may result in obliteration of the septum.
In the elderly, 1. hereditary haemorrhagic telangiectasia may cause prolonged nasal bleeding.
2.(Wegener’s) and pyogenic granuloma may also present with nosebleeds.
Management Positioning
1. If the patient is haemodynamically stable, bleeding can be controlled with first aid measures. This involves:
Asking the patient to sit with their torso forward and their mouth open- avoid lying down unless they feel faint. This decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth. It also reduces the risk of aspirating blood.
Pinch the cartilaginous (soft) area of the nose firmly and consistently for at least 20 minutes and ask the patient to breathe through their mouth.
If first aid measures are successful,
2. Consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis. Cautions to this include patients that have peanut, soy or neomycin allergies, and Mupirocin is a viable alternative.
Criteria for admission:
Admission and follow up care may be considered in patients under if a comorbidity (e.g. coronary artery disease, or severe hypertension) is present, an underlying cause is suspected or if they are aged under two years (as underlying causes such as haemophilia or leukaemia are more likely in this age group).
If bleeding does not stop after 10-15 minutes of continuous pressure on the nose, consider cautery or packing.
REMEMBER !!!!!!
Cautery should be used if the source of the bleed is visible and cautery is tolerated- it is not so well-tolerated in younger children! Packing may be used if cautery is not viable or the bleeding point cannot be visualised. If the nose is packed in primary care, the patient should be admitted to the hospital for review.
Cautery:
Ask the patient to blow their nose to remove any clots. Be wary that bleeding may resume.
Use a topical local anaesthetic spray (e.g. Co-phenylalanine) and wait 3-4 minutes for it to take effect.
Identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.
Dab the area clean with a cotton bud and apply Naseptin or Muciprocin.
Anterior nasal packing posterior nasal packing
Packing:
Anaesthetise with topical local anaesthetic spray (e.g. Co-phenylalanine) and wait for 3-4 minutes
Pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions
Pressure on the cartilage around the nostril can cause cosmetic changes, and this should be reviewed after inserting the pack.
Examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel.
Patients should be admitted to hospital for observation and review, and ENT if available.
Patients that are haemodynamically unstable or compromised should be admitted to the emergency department- control bleeding with first aid measures in the interim. Patients with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital.
Self-care advice involves reducing the risk of re-bleeding. Patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol, or hot drinks should be avoided. The same applies to patients who have just been cauterised, as any strain on the nostril may induce a re-bleed.
