Case Study

A 34 female presents to ED at 2am, post waking up with blood all over her pillow, and a
continuos ooze of blood from her right nostril.
On examination the patient is alert and oriented, BP 110/60, pulse 95, respiratory rate 22, Sp02
98% room air, and has no past medical history. The patient reports having a sinus infection of
late which shes has been using an antihistamine nasal spray to treat.

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Epistaxis:

Epistaxis is a frequent complaint

60% of the populationwill with suffer from a nose bleed during their lifetime, and 6%
will require medical attention.

Majority of epistaxis occurs between the ages of 2-10 and 50-80 years old.

Epistaxis results from an interaction of factors that damage the nasal mucosal lining,
affect the vessel walls, or alter the coagulability of the blood.

Emergency physicians have a 90% success rate at treating epistaxis in emergency

department, and only have to refer 10% to ENT for further assessment and management

Causes of Epistaxis:
Local trauma:

Nose picking
Facial trauma

Foreign bodies

Nasal or sinus infections

Nasal septum deviation

Environmental:

Dry cold conditions (presentations increase during winter)

Prolonged inhalation of dry air (Oxygen)

Iatrogenic:

Nasogastric tube insertion

Nasotracheal intubation

Medicinal:

Topical corticosteroids and antihistamines

Solvent inhalation (huffing)

Snorting cocaine

Anticoagulants: Aspirin, warfarin, platelet inhibitors

Coagulopathies:

Inherited coagulopathies: von Willebrand disease, haemophilia A & B

Splenomegaly

Thrombocytopenia

Platelet disorders

Liver disease

Renal failure

Chronic alcohol abuse

AIDS

Vascular Abnormalities:

Sclerotic vessels
Hereditary haemorrhagic telangiectasia

Ateriovenous malformation

Neoplasm

Aneurysms

Septal perforation/deviation

Endometriosis

Hypertension:

Controversial topic and is often misunderstood in epistaxis see Hypertension and

Epistaxis.
Hypertension is rarely a direct cause of epistaxis

Epistaxis is however more common in hypertensive patients this is postulated to be

caused from long standing hypertension causing vascular fragility of the blood vessels.

Epistaxis in patients presenting to ED, will generally have an associated anxiety that will
increase blood pressure.

Despite multiple causes for epistaxis, literature shows that in 85% of cases no causes in found.
Anatomy and Physiology of Epistaxis:

The nose is supplied with an extensive vasculature with multiple anastomosis.

90% of epistaxis occurs in the anterior nasal septum, from Littles area which contains the
Kiesselbach plexus of vessels.

The other 10% occur posteriorly, along the nasal septum or lateral nasal wall.

The blood supply of the nasal septum is from the internal carotid through the anterior and
ethmoidal arteries, and from external carotid through the greater palatine, spenopalatine
and superior labial arteries.

Anatomy of the Nasal Cavity: Image from:http://3.bp.blogspot.com

Assessment of the patient presenting with Epistaxis:
History:
Obtain the following:

Laterality, duration, frequency

Severity, estimated blood loss

Any contributing or inciting factors

Family history or bleeding disorder

Past medical history

Current medications

Physical Examination:

Focus on trying to identify if the bleed is coming anteriorly or posteriorly.

Suctioning or blowing of the nose to clear away clots, and application of topical
vasoconstrictors or anaesthetics will help with visualisation

Gently insert nasal speculum and spread naris vertically, a good light source will be also
required to assist visualisation of bleeding area.

A posterior source of bleeding is suggested by failure to visualise an anterior source,

bleeding from both nares, and the visualisation of blood in the posterior pharynx.

Investigations:

Patients will large amounts of bleeding should have a full blood count to check
haemoglobin level, and a group and hold incase transfusion is required.
Patients taking warfarin should have an INR checked.

Coagulation studies are only of benefit in patients with a known coagulopathy or chronic
liver disease, and should not be routine in patients presenting with epistaxis.

Other bloods test should only be ordered if past medical history warrants further
investigation (renal failure = U&E, chronic alcohol abuse = LFTs), and literature has
shown they rarely change your management and add considerably to the cost of treating
these patients.

Radiological investigations have little role in the management of epistaxis, CT scan is

indicated if neoplasm suspected, and would generally be arranged post consultation with
your ENT specialist.

Emergency Department Management:

Prehospital Care:

Good effective first aid should stop 90-95% of nose bleeds.

Provide a calm and quite area for the patient to decrease anxiety

The patient should position them self either forward or backward, which ever provides
the most comfort and prevents the patient from swallowing or aspirating any blood
draining into the pharynx. Tip: Fresh blood is irritating to the stomach and will cause
nausea and vomiting.

Pressure should then be applied by pinching the anterior aspect of the nose for 1520mins, which provides tamponade to the anterior septal vessels. Patients should be
shown the correct was to apply pressure by avoiding the nasal bones, by pressing more
distally the nasal ala against the septum.

Some authors advocate placing ice pack to the nape of the neck with belief it produces a
reflex vasoconstriction in the nasal mucosa, however there is little research or evidence to
support this.

Initial Management and Resuscitation:

In extreme cases patients can present with uncontrolled haemorrhage, standard resuscitation
principles should be applied.
Airway:

Risk of airway obstruction from blood in the posterior pharynx, or decreased level of
consciousness from hypovolaemia.
Place patient in postion to assist in managing the blood loss, may require frequent
suctioning.
Be prepared to secure and place a definitive airway (ETT)

Breathing:

Assess depth of breathing and respiratory rate,

Remember a noisy airway is an occluded airway

Provide high flow oxygen via non rebreather mask

Circulation:

Assess heart rate, blood pressure and capillary refill

Patient at risk for severe haemorrhage place x2 large bore IV, check HB, cross match
blood, and start fluid resuscitation

Disability:

Monitor patients level of consciousness this help determine the severity of haemorrhage

Exposure:

Keep patient warm to prevent coagulopathy

If epistaxis is caused by major trauma, always examine from for other injuries

Patients can and have died from epistaxis be prepared to resuscitate!!!

Vasoconstriction:

Vasoconstriction can be achieved by the application of agents topically or soaked cotton

pledgets inserted into the nasal cavity.
Local anaesthesia (Lignocaine) should be used were possible to provide analgesia.

Agents available include 1:1000 Adrenaline, Co-Phenylcaine, and Oxymetazoline, and

are used for their vasoconstriction properties.

Pledget inhalation is a risk especially in patients with decreased level of consciousness

and children.

Vasoconstrictors have been shown to be extremely effective in anterior epistaxis, aid in

the visualisation of the bleeding site, and assist if packing is required.

Following successful application of topical vasoconstriction, patients should be

encouraged to apply topical steroid creams, and petroleum jelly to the nasal cavity
weekly for six weeks, this has been shown to have a 94% success rate of resolution of
symptoms.

Suction:

Suction should be available and easy accessible to help remove clots.

Getting the patient to blow their nose can also be an effective form of suction

An angled Fraser sucker, 10-12 French gauge, is preferred to allow evacuation of the
anterior and middle nasal cavity

Cautery:
Chemical:

Chemical cautery involves the application of silver nitrate sticks, by wiping the tip of the
silver nitrate stick over littles area until it becomes discoloured and grey.
The area should be suctions and as dry as possible to maximise the effectiveness of silver
nitrate sticks, localised pain can occur on application.

The sticks should be applied for 4-5secs until a grey residue or eschar develops.

Only one septum should be cauterised using silver nitrate, as bilateral can cause sepal
perforation

Generally effective in anterior bleeds, however there is a risk of rebleeding.

Electrocautery:

Genrally performed by ENT specialist after effective topical anaesthetic needs to be

provide first.
The red-hot electrocautery loop is passed over the mucosal blood vessels effecting
cautery.
Topical antibiotics and/or petroleum jelly can be used postoperativley.

Packing:

Anterior packing is required when the bleeding fails to stop with vasoconstrictors and
cautery.
Options include traditional nasal packing, a prefabricated nasal sponge, an epistaxis
ballon, or absorbable materials.

Nasal tampons that are moistened, gel-coated, with an inflatable balloon are less painful
and show equal effectiveness when compared to dry hydrophilic nasal tampon

Types of packs:

Traditional Vaseline gauze packing: generally not used these days, as have been
supplanted by readily available and more easily placed tampons and balloons.It consist of
ribbon gauze soaked in petroleum jelly, and is placed in the back of the nasal cavity as far
back as possible, and layered into the naris until it is completely packed. Need to allow
both ends of the gauze protrude from the nose to allow ease of removal.
Compressed sponge/tampon: Merocel is a dehydrated polyvinyl polymer sponge, formed
into flat tampons of various sizes. These are inserted into the nasal cavity, and then
rehydrate by blood or saline, causing then to expand up the three time their original size,
filling the nasal cavity and compressing the source of bleeding.The advantage of these of
gauze packing is that they are technically easier to insert, however literature shows no
difference in patient pain, and ease of removal compared to gauze packing.

Anterior epistaxis ballons: Rapid Rhino consist of an outer layer of carboxycellulose that
promotes platelet aggregation, with an inflatable balloon that compresses the nasal cavity
upon inflation tamponading the bleeding site. Rapid Rhino have been shown to be as
effective as nasal tampons and allow for superior patient comfort on insertion and
removal.

Absorbable materials: various non-absorbable packing materials are available, including

carboxymethycellulose sponges, and calcium alginate dressings and wicks. These
dressing can be left in place for between 1-5 days, but remember the longer the packing is
left insitu the increase risk of developing toxic-shock syndrome.

Posterior Packing/ Ballon Catheters:

Posterior nasal bleeds can be difficult to manage related to the relatively inaccessible site
of bleeding and generally dont respond the above standard medical treatment and
packing.
Analgesia will be required for patients with posterior packing and ballon catheters

Double balloon catheters consist off of a posterior and anterior balloon, are relatively
easy to insert, although cost may limit their use. Generally used in difficult posterior
epistaxis.

The catheter is inserted to the back of the nasopharyngeal space, and then inflate the
posterior balloon first and bring forward sealing off the postnasopharyngeal space. Then
inflate the anterior ballon to apply pressure to the internal cavity of the nose.

Saline is preferred over air to inflate balloon as air can leak out causing deflation and
further rebleeding.

Avoid over-inflating ballon catheters as will cause increased discomfort, rupture of the
ballon, or pressure necrosis of the nasal mucosa.

A foley catheter can be used 10-14 French with 30ml balloon as an alternative.

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Disposition:

Arrange admission for patients with posterior packing, requiring oxygen, and patients
with difficult to manage bleeds.
Patient with anterior packing can generally be discharged home, with packing insitu, with
follow up arranged in 48-72 in the ENT clinic. Provided antibiotics and oral analgesia.

Patients with chronic epistaxis should receive medical followup to investigate anaemia
from chronic blood loss, and coagulopathies.

Uncontrolled severe epistaxis can sometimes require endoscopic cautery, embolization or

artery ligations, patients at risk should receive early ENT review.

Consider Tranexamic acid is severe epistaxis as it works as a potent competitive inhibitor

of plasminogen activator and thus of the fibrinolytic system, and may therefore prevent
clot disintegration and reduce the likleylihood of rebleed.

Medico-legal Pitfalls:

Nasal packing can lead to serious infection (Toxic shock syndrome), most of literature
and ENT specialist recommend prophylactic antibiotics, until evidence supports or
refutes this practise its most probably best practise to follow this and treat with broad
spectrum antibiotics.
Posterior nasal packing places the patient at risk of hypoxia and hypoventilation,
monitoring for this, and implement treatment promptly should it occur.
Nasal packing generally slows or causes cessation of haemorrhage, failure to control
haemorrhage should prompt urgent ENT review.

Recurrent unilateral epistaxis should prompt further investigation to rule out neoplasm.

Nose bleeds occur in those who are beginning to have feeling of lust or who are getting the
signs of manliness.