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Diamond 2014
Diamond 2014
Managing epistaxis
Linda Diamond, PA-C
ABSTRACT
An estimated 60% of the population will have a nosebleed
in their lifetime, and 6% will require medical interven-
tion. Uncontrolled nasal bleeding can lead to hypovolemia
and airway compromise. Understanding prevention and
management of epistaxis is especially important to clini-
cians who manage patients on anticoagulants, supplemental
oxygen therapy, or who have other risk factors for epistaxis.
This article reviews stepwise management for epistaxis and
newer treatment options in adults.
Keywords: epistaxis, nosebleeds, nasal packing, thrombo-
genic agents, balloon catheter, anticoagulation
Learning objectives
Identify risk factors and causes of epistaxis.
Describe the stepwise management of epistaxis.
List the equipment and medications needed to
manage epistaxis.
E
pistaxis is defined as acute hemorrhage from the
nostril, nasal cavity, or nasopharynx. Nosebleeds
are a common condition and most are self-
limiting. However, uncontrolled nasal bleeding can lead
to hypovolemia and airway compromise. This article
reviews the risk factors, prevention, and management
of epistaxis, including management for patients on
anticoagulants or supplemental oxygen. Newer treat-
ment options offer patients and clinicians a better
arsenal to treat epistaxis.
CAUSES
Epistaxis is a frequent phenomenon. An estimated 60%
of the population will have a nosebleed in their lifetime,
and 6% require medical intervention.1,2 The incidence of
FIGURE 1. Anatomy of the nasal cavity
epistaxis is a bimodal distribution, peaking in young
children and again in adults ages 45 to 65 years.2 Epistaxis
can be caused by a variety of factors (Table 1). Antico-
agulation, underlying liver disorders, or other blood
Linda Diamond practices ENT head and neck surgery at Allegheny
General Hospital in Pittsburgh, Pa. The author has disclosed no coagulopathies can contribute to the inability to control
potential conflicts of interest, financial or otherwise. epistaxis. Recurrent or unilateral epistaxis along with
DOI: 10.1097/01.JAA.0000455643.58683.26 nasal congestion or nasal obstruction, independent of the
Copyright © 2014 American Academy of Physician Assistants degree of bleeding, may indicate nasal neoplasm.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CME
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Managing epistaxis
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CME
being further irritated, as can occur during removal of prefer prophylaxis.5 Simple anterior packing on one side
traditional packing. can be treated as an outpatient procedure, with referral to
Thrombogenic agents need to be applied directly to the an ENT specialist for follow-up in 3 to 5 days.
area of bleeding and compression may still be required Patients who require bilateral packing or posterior
initially. When evaluating bleeding, remember that these packing will need hospital admission and monitoring.
agents may take several minutes to work. The potential risk of hypotension and bradycardia caused
by a nasovagal reflex is rare. This “nasopulmonary
TREATING POSTERIOR EPISTAXIS reflex” was thought to occur during posterior nasal
Because visualization and access to the bleeding site is packing or instrumentation but studies have demon-
difficult, posterior epistaxis is challenging to treat. The strated no change in pulmonary or cardiac function in
nares can be packed with petroleum-impregnated gauze relation to posterior nasal packing.6 Patients are at pos-
or a posterior balloon can be placed. A dual balloon sible risk of short-term sleep apnea due to the decreased
catheter is inserted along the floor of the nose until the nasal air entry from the packing.1,4 The risk of displace-
retention ring is at the nasal entrance. The posterior bal- ment of the packing and possible recurrent bleeding
warrants ICU admission or a high level of monitoring.
A hospitalized patient will benefit from a humidified
face tent to provide moisture and comfort; the nasal
Surgical treatment is reserved packing forces patients to breathe through the mouth
while sleeping.
for ongoing hemorrhage that
UNCONTROLLED EPISTAXIS
fails conservative interventions. Angiography with embolization was first performed for
epistaxis in 1972.2 Since then, it has become a common
alternative for uncontrolled epistaxis in medical centers
loon is inflated with 10 mL of sterile water and the cath- where it is available. Patients usually require anesthesia
eter is gently pulled forward until it lodges against the and must tolerate IV contrast for this procedure.
nasopharynx. The anterior balloon is then inflated with Studying endovascular treatment for intractable epistaxis
up to 30 mL of sterile water to hold the catheter in place. in 30 patients, Vitek found a success rate of 87% after
Pad or protect the nasal entrance from any pressure the embolization of the internal maxillary artery and a 97%
balloon may create in its placement. success rate after embolization of the internal and facial
Although not licensed for this use, an indwelling urinary arteries, with a 3% to 4% complication rate.7 Failure of
catheter works well if a balloon catheter is not available. embolization treatment of epistaxis is often related to
Insert a 10-to-14 French catheter into the nasal cavity until continued bleeding from the ethmoidal branches of the
the indwelling urinary catheter is visible in the oropharynx. ophthalmic artery. Embolization of these branches is
Then slowly inflate the balloon with 10 mL of sterile water contraindicated because ophthalmic artery embolization
and gently withdraw the catheter until compression occurs carries a high risk of blindness and stroke.
on the posterior nasopharynx. While maintaining pressure Surgical treatment is reserved for ongoing hemorrhage
on the posterior nasopharynx (pulling the catheter toward that fails conservative interventions. Surgery is performed
yourself), place a small C-clamp or umbilical clamp at the in the OR under general anesthesia; rigid endoscopy
anterior nares to hold the catheter. Ribbon gauze or pack- is used to identify the site of bleeding. Surgical ligation
ing may be placed around the catheter inside the nares for or cautery of the sphenopalatine artery is attempted
added compression and control of bleeding. Apply a gauze initially. Studies of posterior endoscopic cauterization
dressing to protect the external nares from the clamp and report success rates of 80% to 90%.2 If the site of bleed-
pressure necrosis. ing is found from the ethmoidal region, a ligation of the
ethmoid artery is completed. This may require an exter-
AFTER PACKING TREATMENT nal incision through the medial orbital wall just below
After the nasal cavity has been treated or packed, always the eyebrow. Traditional or absorbable nasal packing
use a light source and tongue blade to evaluate the may be placed in the nasal cavity postprocedure as a
oropharynx to check for posterior bleeding. Epistaxis precaution.
that persists after packing is placed requires immediate
referral to an ED. Packing that results in good control ANTICOAGULATION AND HYPERTENSION
should remain in place for 3 to 5 days. Although experts Managing epistaxis in patients taking anticoagulants is
have debated whether to prescribe prophylactic oral challenging. Much debate and little consensus exist as to
antibiotics to prevent toxic shock syndrome and sinus- whether anticoagulation should be continued, held,
itis while the packing is in place, most ENT surgeons or reversed when patients develop epistaxis.3 Medically
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Managing epistaxis
evaluate each patient to determine the risks of stopping history of nosebleeds should add nasal care to their daily
anticoagulation. regime.
The role of hypertension in the initial onset of epistaxis Most nosebleeds are cyclic. A patient may have an
is controversial.8,9 Studies have demonstrated that patients idiopathic nosebleed that stops as a clot is formed over
with epistaxis presenting to the ED have higher BP on the bleeding site. If the patient’s nose becomes dry or is
admission than controls. These patients also have a higher blown and the clot becomes dislodged too soon, the nose
incidence of previous nosebleeds.9 Patients with epistaxis bleeds again. Until the mucosa underlying the clot is
and uncontrolled BP can have persistent bleeding that is allowed to heal, a patient may continue to have serial
difficult to control, so medical management of hyperten- bleeds. Moisture and prohibiting nose-blowing stops this
sion is vital. The hypothesis that elevated BP was second- cycle and lets the nasal lining heal. Teaching patients how
ary to anxiety during epistaxis also was studied. This to correctly try to control a nosebleed and perform proper
prospective comparative study looked at administering nasal care after a nosebleed may prevent an unnecessary
trip to a clinic or ED.
CONCLUSION
Moisture is the key to Epistaxis is a common medical event. Newer treatment
options are available and friendlier for healthcare provid-
prevention. Patients with nasal ers and patients. Creating an epistaxis kit with all necessary
instruments and supplies can help clinicians treat patients
dryness should use saline in an organized, stepwise fashion with confidence. Provide
patients with written instructions about treating nosebleeds
nasal spray. and reducing recurrences. Encourage patients on antico-
agulation or oxygen to perform nasal care on a daily basis
to prevent epistaxis. JAAPA
diazepam to patients with epistaxis, increased BP, and
anxiety. The researchers found that diazepam did not Earn Category I CME Credit by reading both CME articles in this issue,
reviewing the post-test, then taking the online test at http://cme.aapa.
reduce anxiety or BP during acute epistaxis and was not
org. Successful completion is defined as a cumulative score of at
recommended.10 Therefore, evidence supports that hyper- least 70% correct. This material has been reviewed and is approved
tension itself must be controlled in a patient with acute for 1 hour of clinical Category I (Preapproved) CME credit by the
epistaxis and should be monitored closely. AAPA. The term of approval is for 1 year from the publication date of
November 2014.
FOLLOW-UP AND PREVENTION
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.