Epistaxis (Nosebleed)

3.08 Epistaxis (Nosebleed)

Presentation
A patient generally arrives in the emergency department with active bleeding from his nose or spitting up blood that is draining into his throat. There may or may not be a report of minor trauma such as sneezing, nose blowing or nasal manipulation. On occasion the hemorrhage has stopped but the patient is concerned because the bleeding has been recurring over the past few hours or days. Bleeding is most commonly visualized on the anterior aspect of the nasal septum within Kiesselbach's plexus. The anterior end of the inferior turbinate is another site where bleeding can be seen. Often, especially with posterior hemorrhaging, a specific bleeding site cannot be discerned.
What to do:



If significant blood loss is suspected, gain vascular access and administer crystalloid intravenous solution.



Have the patient maintain compression on the nostrils by pinching with a gauze sponge while you assemble all equipment and supplies at the bedside. Inform the patient that you will be controlling the bleeding in a stepwise fashion.



Have the patient sit upright (unless hypotensive) Sedate the patient if necessary with a mild tranquilizer such as hydroxyzine (Vistaril) or midazolam (Versed). Cover the patient and yourself to protect your clothes. Wear gloves.



Prepare 5 ml of 4% cocaine solution or a 1:1 mixture of tetracaine 2% (Pontocaine) for local anesthesia and epinephrine 1:1000 or pseudophedrine 1% (Neo-Synephrine) for vasoconstriction.



Form two elongated cotton pledgets and soak them in the solution.



Use a bright headlight or head mirror to free up hour hands and help insure good visualization.



Have the patient blow the clots from his nose and quickly inspect for a bleeding site using a nasal speculum and Frazier suction tip. Clear out any additional clots or foreign bodies.



Insert the medicated cotton pledgets as far back as possible into both nostrils.



Have the patient relax with the pledgets in place for approximately 5-10 minutes. You may use this lull to ask the patient about any past history of nosebleeds or other bleeding problems, the pattern of this nosebleed, which side the bleeding seems to be coming from, any aspirin or blood thinning medication, and any significant medical or surgical problems.



In the vast majority of cases, active bleeding will stop with this treatment. The cotton pledgets can be removed and the nasal cavity can be inspected using a nasal speculum and head lamp. If bleeding continues, insert another pair of medicated cotton pledgets.



If the bleeding point can be located, cauterize a l cm area of mucosa around the bleeding site with a silver nitrate stick and then cauterize the site itself. Observe the patient for 15 minutes. If this stops the bleeding, cover the cauterized area with antibiotic ointment and instruct the patient in prevention (avoid picking the nose, bending over, sneezing, and straining) and treatment of recurrences (compress below the bridge of the nose with thumb and finger for five minutes).



If the bleeding point cannot be located or if bleeding continues after cauterization, insert an anterior pack. The best is a 1 cm by 10 cm stick of compressed cellulose which expands to conform (Merocel, Rhino Rocket). To prevent putrification of the pack, partly cover it with antibiotic ointment before insertion. Leave some cellulose exposed to allow for water absorption. Instill a few drops of saline if it does not expand spontaneously.



An alternative anterior pack can be made from up to six feet of half-inch ribbon gauze impregnated with petroleum jelly (Vaseline). Cover the gauze with antibiotic ointment and insert it with bayonet forceps. Start with 3-4 plies layered accordian fashion on the floor of the nasal cavity, placing it as far posteriorly as possible, and pressing it down firmly with each subsequent layer. Continue inserting the gauze until the affected nasal cavity is tightly filled (expect to use about 3 to 5 feet per nostril). If unilateral anterior nasal packing does not provide enough pressure, packing the opposite side of the nose anteriorly can sometimes increase the pressure by preventing the septum from bowing over into the side of the nose that is not packed.



Observe the patient for 15 minutes. If no further bleeding occurs in the nares or the posterior oropharynx, discharge him on a broad spectrum antibiotic (amoxicillin tid 250mg) for five days to help prevent a secondary sinusitis. The packing should be removed in 2-4 days.



Tape a small folded gauze pad beneath the nose to catch any minor drainage. The patient can replace this from time to time if necessary.



Instruct the patient against sneezing with his mouth closed, bending over, straining, or nose picking. The patient's head should be kept elevated for 24-48 hours. Provide detailed printed instructions on home care.



If the hemorrhage is suspected to have been severe, obtain orthostatic blood pressure and pulse recordings along with an hematocrit before making a disposition for the patient.



If the hemorrhage does not stop after adequate packing anteriorly, then one or two posterior packs or nasal balloons should be inserted, and the patient should be admitted to the hospital under the care of an otolaryngologist.
What not to do:



Do not waste time trying to locate a bleeding site while brisk bleeding obscures your vision in spite of vigorous suctioning. Have the patient blow out any clots and insert the medicated cotton pledgets.



Do not get routine clotting studies unless there is other evidence of an underlying bleeding disorder.



Do not cauterize or use instruments within the nose before providing adequate topical anesthesia (some initial blind suctioning may, however, be required to clear the nose of clots before instilling anesthetics).



Do not discharge a patient as soon as the bleeding stops, but keep him in the ED for 15-30 minutes more. Look behind the uvula. If it is dripping blood, the bleeding has not been controlled adequately. Posterior epistaxis typically stops and starts cyclically and may not be recognized until all the above treatments have failed.
Discussion
Nosebleeds are more common in winter, no doubt reflecting the low ambient humidity indoors and outdoors and the increased incidence of upper respiratory tract infections. Troublesome nosebleeds are more common in middle-aged and elderly patients. Causes are numerous: dry nasal mucosa, nose picking and vascular fragility are the most common, but others include foreign bodies, blood dyscrasias, nasal or sinus neoplasm or infection, septal deformity, atrophic rhinitis, hereditary hemorrhagic telaniectasis and angiofibroma. High blood pressure makes epistaxis difficult to control but is rarely the sole precipitating cause.
Drying and crusting of the bleeding site, along with nose picking, may result in recurrent nasal hemorrhage. It may be helpful to instruct the patient on gently inserting Vaseline onto his nasal septum once or twice a day to prevent future drying and bleeding. Other useful techniques include electrocautery down a metal suction catheter, ophthalmic electrocautery tips (see subungual hematoma), submucosal injection of lidocaine with epinephrine, and application of hemostatic collagen (Gelfoam). There are also several balloon devices to provide anterior and posterior tamponade, some with a channel to maintain a patent nares. Because of the nasopulmonary reflex, arterial oxygen pressure will drop about 15mmHg after the nose is packed, which can be troublesome in a patient with heart or lung disease, and usually requires hospitalization and supplemental oxygen.
References:



Viducich RA, Blanda MP, Gerson LW: Posterior epistaxis: clinical features and acute complications. Ann Emerg Med 1995;25:592-596.