EPISTAXIS
VTS presentations April 2013
Elisabeth Maskrey
EPISTAXIS CAN BE SERIOUS ……
Epistaxis – the facts
• ~ 60 % of the general population has had at least one episode of
epistaxis
• only 6% sought medical help
• 1.6 in 10,000 required hospitalisation
• the incidence peaks < 10 and >50 years
• rare in children < 2 years, if present is often associated with injury or
serious illness
• Types:
• anterior bleeding
• posterior bleeding
• may present as hematemesis,nausea, anemia,
hemoptysis,melena
Epistaxis - risk factors
• climate
• deviated nasal septum
• Trauma
• inflammation
• irritant chemical exposure
• Disorders of platelet function
• Drugs
• Abnormalities of blood vessles - elderly arteriosclerotic vessels,
hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber
syndrome)
• Malignancy of the nose - juvenile angiofibroma
• Wegener's granulomatosis and pyogenic granuloma
Epistaxis – Hx, examination and Investigations
ABC to confirm haemodynamic stability
Hx
• laterality, duration, frequency, and severity
• PMHx including any conditions predisposing to bleeding - coagulopathies
• current medication - aspirin or warfarin
• FHx of bleeding disorders
• history of recent trauma or surgery
• presence of unilateral symptoms like nasal obstruction, rhinorrhea, facial pain, or evidence of cranial neuropathies
(facial numbness, double vision) indicating benign or malignant sinonasal neoplasms
Examination
• Ideally Thudicum nasal speculum under adequate lighting to identify bleeding points
• if a blood clot is present, advice the patient to blow their nose (with caution) or suction
• topical sprays containing a combination of anesthetics and vasoconstrictors can be used to control bleeding
Investigations
• Sever hemorrhage – FBC, coag, G&S and CXM
• On warfarin - FBC, coag
• Systemic conditions – LFT and U&E
Management
Direct pressure
• Sit patient upright, leaning slightly forward
• Patient squeezes the bottom part of the nose (NOT the bridge of the nose) for
10-20 minute
• Monitor HR and BP
• If bleeding has stopped after this time inspect the nose using a nasal speculum
and consider cautery.
Cauterisation
• Apply a silver nitrate cautery stick for 10 seconds
• working from the edge and moving radially
• Never both sides of the septum at the same session.
Cream (Naseptin)
• Cautery and cream are equally effective for the treatment of epistaxis.
• Application of a cream-based treatment may initially be easier and more
practical, particularly in children
Management
Anterior packing
• nasal tampon
• absorbs blood, swells and the tight fit reduces flow.
• Lubricate the tampon with K-Y Jelly or Naseptin cream
• secure the tampon thread to the cheek
• Pack the other side as well.
• Packs are generally left in place for 24 hours.
• Can also use 1 cm ribbon gauze impregnated with petroleum jelly . Both ends of the gauze
should protrude from the nostril.
Posterior bleeds
• May require ENT input
• packing and a balloon catheter can be useful
• Opiate analgesics to relieve discomfort and reduce elevated blood pressure due to
posterior pack.
• Ligation of the sphenopalatine artery endoscopically.
Management
Complications of packing
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•
•
•
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Anosmia
Pack falling out and continued bleeding
Breathing difficulties and aspiration of clots
Posterior migration of the pack causing airway obstruction and asphyxia
Perforation of the nasal septum or pressure necrosis of cartilage
Summary
• If sever get specialist help
• For recurrent cases consider underlying causes
• Can be managed quickly and easily in most cases
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