EPISTAXIS
Never underestimate nosebleeds they can be fatal! The commonest ENT emergency
by far.
Causes:
Unknown:
in 80% of cases. The peak incidence occurs in children, young
adults, and those 50 or over. There is a seasonal variation,
nosebleeds are more common in cold weather.
Trauma:
Also common (nose picking) due to excellent vascularisation in
Little’s area (close to the nasal opening
Other:
decreased haemostasis, haemophilia, excessive alcohol,
Hypertension is not regarded as a cause although it can prolong bleeding.
Ask about NSAIDS and anticoagulant use.
Rare:
hepatic coagulopathy, Osler-Weber-Rendu syndrome,
leukaemia, malaria and typhoid.
Management:
ABC:
First Aid:
Further treatment:
Anterior epistaxis:
Posterior epsitaxis:
Never forget ABC, always thinking of fluids. Resus the patient
if necessary.
unless the patient is shocked, have them sitting up with the
head tilted downward to prevent blood trickling backwards.
Firm pressure on the cartilaginous nose (not the bridge) for 1015 minutes
Most nosebleeds will stop with pressure, but if not, try to
visualise bleed. This is easier said that done.
This is almost invariably septal.
1. remove clotts with suction, or by asking patient to blow
their nose
2. insert a cotton wool pledget or a length of ribbon gauze
soaked in a vasoconstrictor and/or local anaesthetic – into
the nostril for 5 minutes. This should slow the bleeding and
anaesthatise the area.
3. Obvious anterior bleeding can be cauterized with silver
nitrate sticks. Warn that it stings.
4. Bleeding that persists can be treated with anterior packing
with Vaseline and BIPP impregnated ribbon gauze or nasal
tampons.
Tends to be major or more severe than anterior. Watch out for
shock, especially in the elderly. The gold standard treatment is
visualisation with endoscopy and then cauterization.
If bleeding site cannot be found, the nose may be packed with
gauze. Bleeding arising more posteriorly usually requires
posterior packing: Pass a 16-18G foley catheter through the
nose into the pharynx, then inflate with 10ml of water, then pull
until it get’s stuck. Then place an anterior pack, and secure it.
Packing is generally left for 48h. There are well-recongised
problems with infections and hypoxia. Therefore if packs
remain in for >48h then consider close monitoring or
prophylactic antibiotics
Persistant posterior epistaxis:
1. Examination under GA.
2. Ligation