Epistaxis

Epistaxis is a common presentation to the Emergency Department (ED). Data from the United States suggest that epistaxis accounts for approximately 1 in 200 visits to the ED [1]. In the United Kingdom, one study found a rate of ED attendance with epistaxis to be around 100 per 100,000 population served by the department [2]. It is likely that a large percentage of ED presentations could be avoided by appropriate use of first aid techniques. However, surveys of the general public and those at particular risk (patients taking anticoagulant medication), have shown a clear lack of knowledge in these techniques [3,4,5]. Unfortunately, this is compounded by a lack of first aid knowledge [6], provision of basic equipment and specific epistaxis teaching [7] for ED staff. A co-operative and well defined management strategy can, however, result in 85% of patients with epistaxis being successfully managed by Emergency Physicians without specialist input or admission [8].

Learning Bite

With a well defined management strategy, 85% of epistaxis patients can be managed in the ED without specialist input or admission.

Epistaxis can be defined as haemorrhage from the nostril, nasal cavity or nasopharynx. It is customarily split into anterior and posterior types. Anterior epistaxis accounts for approximately 95% of all cases of epistaxis [9]. It can also be subdivided into traumatic and non-traumatic although traumatic is normally used to imply significant external injury to the nose, usually arising as a result of a fall or assault. A high percentage of so-called non-traumatic epistaxis is due to local minor trauma to the nasal mucosa e.g. nose picking or rubbing.

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Approximately 95% of all nosebleeds arise from the anterior nasal cavity.

An appreciation of the vascular anatomy of the nose is crucial in an understanding of the pathophysiology of epistaxis. The anterior nasal septum is the location of number of arterial anastamoses between vessels arising from branches of the internal and external carotid arteries. This series of anastamoses are formed into a triangular shape [10], and known as Kiesselbachs plexus. The area of the nasal septum involved is commonly referred to as Littles area.

The large number of vessels concentrated in this area play an important physiological role in thermal regulation, humidification of inhaled air and control of the lumen of the nasal passages.

Bleeding not arising from Kiesselbachs plexus, referred to as posterior epistaxis, may originate from any part of the remainder of the nasal cavity or nasopharynx.

Although it is recognised that any local inflammation or trauma is likely to result in a nosebleed, the precise mechanisms by which most epistaxis occurs are still poorly understood. It is known that epistaxis presentations to the ED are more common in the winter months [1], probably reflecting a higher incidence of upper respiratory tract infections and lower atmospheric humidity. There are also two well defined peaks in epistaxis prevalence occurring at the extremes of age [1] which may reflect different aetiological causation. In children it is hypothesised that staphylococcal colonisation of the anterior nasal cavity is an important factor in both producing crusting of the mucosa and subsequent epistaxis [11].

In adults, a number of different aetiological associations have been described. Recent heavy (within 24 hours) or regular high alcohol intake is associated with an increased risk of non-traumatic epistaxis [12], probably as a result of the effect of alcohol on bleeding time [13]. Any coagulopathy or medication affecting haemostasis [14] also increase the risk of epistaxis. Other factors that have been described to increase epistaxis risk include surgery, local malignancy and aneurysms, nasal septal deviation and use of drugs, including drugs of abuse, acting on the nasal mucosa e.g. cocaine [15]. The association of epistaxis with hypertension is more complex and remains unclear. Although ED patients presenting with epistaxis have been shown to have higher blood pressures than a control group [16], a large population based study has failed to show a link [17] between the two.

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Both recent heavy drinking and long term high alcohol intake are associated with an increase in the risk of non-traumatic epistaxis.

Assessment of a patient with a history of bleeding, even if it appears to have stopped, must start with an initial ABC assessment concentrating on the airway and haemodynamic status. If the patient is still actively bleeding and there is evidence of haemodynamic compromise, then both resuscitative and first aid measures should be started immediately.

First aid measures to stem nasal bleeding:

• Lean the patient forwards in an upright position to avoid the passage of blood into the nasopharynx. Encourage the patient to spit out any blood passing into the throat and not swallow it.
• Ask the patient to firmly pinch the soft part of the nose compressing the nostrils for at least 10 minutes. If unable to comply then an alternative technique is to ask a relative or staff member or apply an external pressure device such as a swimmers nose clip [18]
• Application of ice to the neck or forehead has not been shown to influence nasal blood flow [19,20]. However, sucking on an ice cube has been shown to reduce nasal blood flow [20] and applying an ice pack ice directly to the nose may help

Treat epistaxis as a circulatory emergency depending on the severity especially in the elderly, patients with clotting disorders or bleeding tendency and those on anticoagulants. Always insert atleast a green IV cannula and to make sure to send the FBC, U&Es, clotting and group and save (depending on blood loss) in these patients. Also try to allocate them in majors or area where they are closely observed as some times dislodgement of blood clot could lead to a catastrophic bleed in these patients.

Whilst first aid measures are taking place, a history should be taken which should include the following;

• Side, duration and approximation of amount of bleeding (see below)
• History of trauma
• Previous episodes and treatment
• Recent upper respiratory tract infection or rhinitis
• The presence of bleeding or bruising elsewhere on the body
• Other significant co-morbidities particularly those which may affect coagulation (e.g. liver disease)
• Medication, concentrating on drugs known to affect coagulation
• Use of drugs of abuse, in particular cocaine
• Alcohol history
• In children, the child and parent should be asked about the possibility of a foreign body in the nose.

Examination of the patient must include a general assessment of cardiovascular and respiratory status as well as looking for any evidence of signs consistent with a pre-existing coagulation disorder e.g. petechiae, purpura, hepatosplenomegaly and lymphadenopathy. The presence of any of these findings should prompt further investigation once the epistaxis has been adequately managed.

Examine oropharynx with the help of tongue depressor if the bleeding stops or history suggestive of posterior epistaxis. Also examine nostrils for blood clots and have suction apparatus and a bowel ready before dislodging the clots as that can lead to rebleed.

Only one attempt has been made to risk stratify patients with epistaxis. This described the development of an epistaxis scoring system in children [21]. However, this score has not been further validated or utilised in clinical practice in children or adults, and its use in a retrospective review of children with recurrent epistaxis did not find the score a useful screening tool for identifying those with a higher risk of an undiagnosed coagulopathy [22].

If the patient is normally fit and well without significant co-morbidity, history or evidence of coagulopathy and disturbance of haemodynamic observations, formal blood tests are not required. Clearly however, the presence of any of these factors should prompt appropriate investigation which may include blood tests, ECG and x rays.

The ordering of routine coagulation studies has been the subject of two retrospective case reviews which concluded that they are unnecessary unless there is a personal or family history of a coagulation disorder [23,24].

Learning Bite

Coagulation studies should not be ordered in patients with epistaxis unless there is a personal or family history of a coagulation disorder.

For optimum management of epistaxis, it is crucial that a clear ED management protocol [25] or epistaxis ladder [26] is developed in co-operation with the local Otolaryngology department. Protocols should outline a staged process where treatment of a patient with epistaxis, starts with the simplest and least invasive techniques moves through more advances procedures and finishes with guidance on situations where specialist input is needed [7,8].

Having first ensured that appropriate resuscitative and first aid measures have been applied, further management begins by ensuring the clinicians personal protection. Epistaxis presents a particularly high risk of blood contamination due to bleeding directly into the airway and therefore an increased likelihood of droplet spread. Practitioner contamination beyond gloves was found to occur in 55% of patients [27] and ocular contamination was found in up to 18% of cases [28]. Clinicians should therefore be equipped with a minimum of gloves, mask and visor.

Covering the patients mouth with a facemask will also ensure that any coughed or expectorated blood is caught [29].

Once verbal consent has been obtained, the anterior nose should be cleared with gentle suction. A cut down flexible suction catheter may be less traumatic than a rigid catheter [30]. The site of bleeding should be identified and a combination local anaesthetic vasoconstrictor agent then applied to the anterior nose by either a spray or cotton wool pledget. After waiting for the anaesthetic vasoconstrictor agent to take effect, further visualisation should reveal a clearer view of the anterior nasal cavity. If a visible vessel or localised area of bleeding is seen then it should be cauterised, either by direct application for no more than [30] seconds in any one spot [31] or, if bleeding is too brisk for the cautery to be effective, by cauterising the four quadrants immediately around it (doughnutting the bleeding site).

A comparison of silver nitrate tipped applicators and hot wire electrical cautery found them to be equally effective in stopping bleeding [32]. Both sides of the septum must not be cauterised in the same treatment as there is a risk of septal perforation due to decreased vascular supply from the perichondrium. Excess silver nitrate can be removed by application of a saline soaked pledget to the area which neutralises the silver nitrate preventing staining and unwanted areas of burning [33]. Observe the patient for 15 minutes after the procedure to ensure bleeding is controlled, prior to discharge.

In children, it is normally the case that adequate first aid measures will stop bleeding. In this situation, inspection of the anterior nasal cavity will commonly reveal either crusting of the anterior nasal mucosa or a visible vessel. A Cochrane review [34] and two RCTs [35,36] have compared application of antiseptic nasal cream (e.g. Naseptin) with silver nitrate cautery in children with recurrent epistaxis and found no significant difference between the two in the frequency of recurrent bleeding. The use of silver nitrate cautery was also associated with greater pain. Children with recurrent nose bleeds and nasal crusting should therefore be treated with topical nasal antiseptic cream applied twice daily for 4 weeks. In the presence of a visible vessel on the septum, cauterisation with silver nitrate is recommended [37].

Learning Bite

Topical antiseptic cream is as effective as silver nitrate cautery in preventing further nosebleeds in children with recurrent epistaxis.

In adult patients especially on antiplatelet drugs (Aspirin), treatment with topical application of TXA soaked cotton pledget (500 mg TXA in 5 ml) is painless, rapid and effective approach to achieving hemostasis in anterior epistaxis who fail direct pressure and can be tried prior the placement of an anterior nasal pack with no evidence of serious adverse effects [45].

If first aid measures and attempts at cautery are unsuccessful or there is bilateral bleeding, then the nose should be packed. Traditional ribbon gauze soaked in BIPP packing has been superseded by the development of nasal tampons. There are two main types of tampon, the compressed sponge (e.g. Merocel, Rhino Rocket) type and the inflatable balloon tampon (e.g. Rapid Rhino)

A small prospective RCT compared Merocel pack with a traditional ribbon gauze and found no difference between the two in terms of effectiveness and patient preference but the Merocel pack is far easier to insert [38]. Two prospective RCTS have compared a compressed sponge tampon to the Rapid Rhino and found the Rapid Rhino to be as effective in controlling the epistaxis but less painful to insert and easier to remove [39,40]. Once an anterior pack has been placed it is important to observe the patient for a minimum of 30 minutes to check no further leakage occurs either from the nose or posteriorly into the pharynx.

There are two sizes of Rapid rhio nasal packs ie 5.5cm and 7.5 cm. Immerse in saline or distilled water before insertion and for all anterior nasal packs, try to place them as horizontally as possible to prevent misplacement. For rapid rhino inject air to the amount either tolerated or cause haemostasis as too much air instillation could lead to more patients discomfort as well as could lead to pack trauma. For Merosel packs, ideally apply antiseptic cream like Naseptin before the insertion and once inserted, instill few mls of saline or distilled water for the pack to expand. Secure the threads of Merosel or tube end of rapid rhino with tape applied on to nose or face.

Make sure to re-examine the oropharynx after the nasal pack for blood diversion or poster epistaxis.

Learning Bite

When packing the anterior nose, inflatable balloon tampons (e.g. Rapid Rhino) are the least painful to insert and easiest to remove.

Failure of an anterior nasal pack to stop epistaxis is most likely due to bleeding arising from the posterior nasal cavity. In this situation a variety of management options are available including endoscopy with cauterisation, ligation of the sphenopalatine artery and posterior packing. The further management of posterior epistaxis is the province of the Otolaryngology department. If there is likely to be a significant delay before specialist input or the patients haemodynamic status is deteriorating, then Foley catheters can be used as a temporary solution in the ED. Size 12 or 14 gauge catheters should be advanced one at a time through the nostril, along the floor of the nose into the nasopharynx until seen in the pharynx. Each balloon should be inflated with 5 10 mls water and gentle traction applied.

Learning Bite

Insertion of foley catheters to stop uncontrolled posterior bleeding is a technique of last resort when immediate specialist help is unavailable.

Traditional management of the epistaxis patient mandated admission for patients with bilateral ribbon gauze packs due to fears of potential airway compromise. Reductions in FRC, RV and TLC [41] and increased pCO2 and falls of pO2 [42] have been demonstrated in patients with bilateral ribbon gauze nasal packs. With the advent of nasal tampons, epistaxis protocols have been developed and evaluated which allow for the safe discharge of specific groups of patients with early review in the ENT clinic [8,25]. However, these protocols still suggest that specific groups of patients with anterior packs in place are admitted for further observation.

• Traumatic cause for the epistaxis
• Haemodynamic compromise or shock
• Previous nasal packing within the last 7 days
• Patient is taking anticoagulant medication
• Measured haemoglobin less than 10 g/dl
• Uncontrolled hypertension
• Significant co-morbid illness
• Adverse social circumstances (e.g. the patient lives alone or more than 20 minutes away from the hospital or has no access to telephone or transport)
• Patients personal preference

The use of these protocols was accompanied by a readmission or significant complication rate of between 9 and 11% and therefore providing comprehensive discharge advice is important.

No follow-up is necessary for patients in whom the epistaxis has either stopped spontaneously or by first aid measures or cautery alone. However it is important to provide advice to prevent recurrence of the nosebleed and first aid measures for future episodes. This should include avoidance of;

• Blowing the nose for one week.
• Sneezing through the nose keep the mouth open.
• Hot and spicy drinks and food, including alcohol for two days.
• Heavy lifting, straining or bending over.
• Vigorous activities for one week.
• Picking the nose.

For those patients who have an anterior nasal pack, it should be left in place for 24-48 hours and follow-up arranged with the Otolaryngology department for its removal and further assessment. There is no evidence that routine antibiotic cover is required for patients with an anterior nasal pack in place for less than 48 hours [43].

Learning Bite

Routine antibiotic cover is unnecessary for patients with an anterior pack in place for less than 48 hours.

Estimation of the severity of blood loss either from the patients account and/or blood-stained clothing and towels is notoriously unreliable. A study of blood loss estimation in epistaxis revealed a consistent underestimation by ED medical and non-medical staff, sometimes by up to 50% [44].

• In 95% of cases, epistaxis arises from the anterior nasal septum due to the presence of a number of arterial anastamoses (level of evidence 4).

• First aid management of epistaxis should include leaning the patient forwards, pinching of the nose to occlude the nostrils and application of an ice pack to the nose or sucking on an ice cube (level of evidence 4).

• Personal protective equipment is vital when managing epistaxis as blood contamination beyond gloves occurs in over half of clinicians treating epistaxis (level of evidence 4).

• With a clear management protocol, 85% of patients with epistaxis can be safely treated and discharged from the Emergency Department (level of evidence 4).

• Topical nasal antiseptic cream is as effective as silver nitrate cautery in preventing recurrent nosebleeds in children with epistaxis (level of evidence 2b).

• An inflatable balloon tampon (e.g. Rapid Rhino) is as effective in stopping anterior nasal bleeding as a compressed sponge (e.g. Merocel) tampon but is less painful to insert and easier to remove (level of evidence 2b).

• Most patients can be discharged home following insertion of an anterior nasal pack, provided they have been given appropriate discharge instructions and follow-up (level of evidence 4).

• Antibiotic cover is unnecessary for patients with an anterior nasal pack, provided it is removed within 48 hours (level of evidence 5).

Learning Bite

Always treat epistaxis as a circulatory emergency especially in high risk patients and with deranged vital signs.

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