Makindo Medical Notes.com

The blood supply of the nose is vulnerable to bleeding and damage as it lies very superficial. The role of the nose and its vasculature is to both humidify and warm the incoming air, which it does remarkably well...at a price that is a vulnerability to excessive bleeding. Do not underestimate the blood loss from epistaxis.

About

• Epistaxis is bleeding from the nose, caused by damage to the blood vessels of the nasal mucosa
• Usually mild and inconsequential but in rare cases potentially life-threatening
• Patients can have significant bleeding which is occult as the patient swallows the blood.
• Treat epistaxis seriously and keep a watch for signs of haemodynamic compromise - tachycardia, postural hypotension etc.

Anatomy

Aetiology

• 90% of nosebleeds originate from Kiesselbach's plexus (Little's area) which lies quite anterior
• Posterior bleeds are rarer but more difficult to treat and arise from Woodruff's plexus.
• Severe bleeding may be arterial from the sphenopalatine artery.
• Management is more difficult as it is not directly compressible. Seen more so in the elderly and tends to be more severe.

Risk Factors

• Hypertension, Bleeding disorders, anticoagulants
• Previous epistaxis/cautery, recent nose trauma
• Recent upper respiratory tract infection, Nasal foreign body
• Cocaine use, Nose picking
• Atherosclerosis, increased venous pressure from mitral stenosis,
• Haem disorders (thrombocytopenia, leukaemia, and haemophilia)
• Excessive alcohol consumption.

Clinical

• One should enquire about a patient history or family history of a bleeding disorder - haemophilia, Von Willebrand's disease, Osler Weber Rendu syndrome, Thrombocytopenia.
• Ask about use of Warfarin, Aspirin, Clopidogrel, NSAIDs

Investigations

• Check FBC. U&E and Coagulation screen if coagulopathy suspected or on warfarin or heparin
• Consider Group and save and Cross-matching if severe

Complications of epistaxis

• Rare and include hypovolaemia, anaemia, and even shock.
• Also complications from nasal packing treatment.

Management

• ABC. Significant blood loss which may be occult should warrant urgent IV access and blood taken for group and save. Monitor Clinical Signs.
• Most Epistaxis settles with direct pressure such as pinching the tip of the nose for 10-15 minutes with the patient sitting forwards. If the person is haemodynamically compromised, epistaxis should be managed as an emergency, and immediate transfer to Accident and Emergency should be arranged. First-aid measures should be used whilst awaiting the ambulance: The person should sit with their upper body tilted forward and their mouth open; the soft part of the nose should be pinched firmly and held for 10–15 minutes.
• If a posterior bleed is suspected (bleeding is profuse, from both nostrils, and the bleeding site cannot be identified on examination), admission to the hospital is recommended.
• If the bleeding stops with first aid measures, a topical antiseptic such as Naseptin® (chlorhexidine and neomycin) cream may be applied to prevent re-bleeding. After bleeding has stopped advice against nose picking and heavy lifting for 24 hours after bleeding
• If bleeding does not stop after 10–15 minutes of adequate pressure to the nostrils, nasal cautery or nasal packing may be used to stop the bleeding if the appropriate expertise and facilities are available in primary care. Otherwise, immediate transfer to Accident and Emergency is recommended.
• Remove any clot and apply adrenaline (1:1000) soaked pledget used with lidocaine as a topical anaesthetic
• Attempt Cautery with silver nitrate sticks. Anterior (unilateral then bilateral) bleeds - Packing, Tampons, Balloons
• Posterior bleeds - Packing, Saline-filled Foley catheter + Antibiotics and get an ENT
• No nose blowing/picking for a week, Sneeze with mouth open
• Avoid Aspirin/NSAIDs/Anticoagulants - best to omit but take expert advice if unsure.

General

• If first aid measures or nasal cautery employed in primary care have resulted in cessation of bleeding, offer self-care advice. Recommend that for 24 hours, where practical, the person should avoid activities which may increase the risk of re-bleeding.
• These include: Blowing or picking the nose. Heavy lifting. Strenuous exercise. Lying flat. Drinking alcohol or hot drinks. Advise the person that if bleeding restarts and does not respond to first aid measures (as above) they should seek urgent medical advice.

Notes on Nasal Cautery

• Consider nasal cautery if first aid measures have not worked, and the appropriate expertise and facilities (good lighting, topical anaesthetic spray, and nasal speculum) are available, and It can be tolerated (for example in adults and older children, but not younger children).
• Prior to cautery: Ask the person to blow their nose to clear any clots and allow local anaesthetic to be applied. This may restart the bleeding.
• Use a topical local anaesthetic spray, preferably with a vasoconstrictor (such as lidocaine with phenylephrine [Co-phenylcaine®]), prior to cauterizing the area. Wait 3–4 minutes for the full effect. The vasoconstrictor may stop the bleeding, but once the effects have worn off, the bleeding may start again.
• To cauterize: Identify the bleeding point — it will look like a small red dot (less than 1 mm) and may not be actively bleeding. Lightly apply the silver nitrate stick to the bleeding point for 3–10 seconds until a grey-white colour develops.
• Only cauterize one side of the septum to avoid nasal septal perforation. Avoid touching areas which do not need treatment (for example facial skin).
• After cautery: Dab the cauterized area with a clean cotton bud to remove excess chemical or blood. Apply a topical antiseptic preparation to the area: Prescribe Naseptin® (chlorhexidine and neomycin) cream first line, to be applied to the nostrils four times daily for 10 days. If the person is allergic to neomycin, peanut, or soya, do not prescribe Naseptin®. Consider prescribing mupirocin nasal ointment to be applied to the nostrils two to three times a day for 5–7 days.
• Do not routinely pack the affected side. Advise the person to avoid blowing their nose for a few hours to prevent straining of the nostril.

Notes on Nasal Packing

• Consider if: Nasal cautery has been ineffective or the bleeding point cannot be seen, and the appropriate expertise and facilities (good lighting, topical anaesthetic spray, and nasal speculum) are available.
• Prior to packing: Anaesthetise the nasal cavity with topical local anaesthetic spray, preferably one with a vasoconstrictor (for example lidocaine with phenylephrine [Co-phenylcaine®]), if this has not already been done. Wait 4 minutes for the full effect.
• Nasal packing products e.g. Nasal tampons (for example Merocel®) effective and easy to use. Inflatable packs (for example Rapid-Rhino®) are effective and may be easier and more comfortable to insert and remove than nasal tampons. Ribbon gauze impregnated with Vaseline® or bismuth-iodoform paraffin paste — packing with ribbon gauze is not recommended in primary care without specific training.
• Insert the packing according to the manufacturers' instructions. Pack the person's nostril whilst they are sitting with their head tilted forward. Ensure that the person is holding a receptacle to spit blood out in, and is breathing through the mouth.
• Secure the pack (for example Merocel® packs have a string attached which can be taped to the cheek), and ensure there is no pressure on the cartilage around the nostril as this can cause a cosmetic defect.
• Check the oropharynx for signs of bleeding from the back of the nose. If bleeding is seen, consider packing the other nostril to increase pressure on the bleeding vessel.
• Admit the person to hospital for observation, preferably to an ear, nose, and throat department.

Algorithms

References

• Epistaxis management