Epistaxis

Question 1

A 65 year old man presents to the ED with a severe nosebleed. He has a history of poorly controlled hypertension. How would you manage him?

Answer 1

Impression
Severe epistaxis. Concerned about airway risks, risk of aspiration, but also hypovolaemia in setting of ongoing blood loss and subsequent shock.

Considerations regarding DDs;

• trauma: rule out septal haematoma
• anticoagulants, need for reversal?
• location of bleed: anterior (most common @ keisselbach plexus) or posterior.

Goals

• Call for senior help, assess for HD stability before continuing with targeted Hx/Ex/Ix
• Acutely manage with appropriate posturing, compression, and then consider chemical/electrical cautery options for definitive treatment

Question 2

Epistaxis - Assessment

Answer 2

Assessment
- A: patent, maintaining - blood in airway consider suction. Position patient to sit upright and lean forwards so blood moves out of airway rather than down it
B - as per
C - HR/BP monitoring. ECG. If HD instability and evidence of hypovolaemia then 2xIVC for initial bloods (G+xmatch, FBC, VBG, coags, UEC). Consider resus with 0- then matched blood, reversal of anticoagulation as appropriate
Stop bleeding:
o compression of anterior nasal septum
o nasal packing with nasal tampon
o Spray nose with topical analgesia + adrenaline for vasocontraction
o chemical cautery/electrical diathermy (probs not in ED)
D - GCS
EFG

Question 3

Epistaxis - History

Answer 3

History

• PC: timing, onset, MOI/trigger for bleed? estimated volume of blood loss.
• Sx: pain (SOCRATES), consequences of blood loss (light-headed, SOB, chest pain, LOC), any aspiration? cough, pleuritic chest pain
• HPI: happened before?
• Risks: anticoagulation, nasal polyps, recent trauma/surgery, chronic liver disease
• Meds, allergies, PMHx, SNAP

Question 4

Epistaxis - Examination

Answer 4

Examination
- General appearance + vitals
- Nose examination - identify source of bleed, utilise a nasal speculum for complete examination
o administer anaesthesia with nose swabs/gauze
- Signs of coagulopathy: petechiae, bruising, ecchymoses
- Assess for signs of uncontrolled hypertension

Question 5

Epistaxis - Investigations

Answer 5

Investigations

- Labs: FBC, UEC, LFT, Coags, G+H if massive/prolonged/HD unstable

Question 6

Epistaxis - Management

Answer 6

Management
In most cases, management is supportive (as per A to E Assessment and management)
Step-wise approach
- Compression
- Spray lidocaine + adrenaline, or apply via gauze
- Cold compress
- Chemical/electrical cautery
- nasal packing +/- contralateral nostril

Considerations
- ENT referral for continuous bleeding
o Foley catheter
o surgical intervention +/- angiographic embolisation

Management of hypertension
- manage in GP setting, unless evidence of end organ damage or hypertensive urgency/emergency

Patient education
- avoid blowing nose, strenuous activity, heavy lifting, picking nose