Epistaxis

Question 1

Concerning features with active bleeding

Answer 1

Severe bleeding
Abnormal vital signs, drowsiness, or confusion

Question 2

Treatment if active bleeding

Answer 2

Sustained firm pressure to the nasal alae with thumb and index finger with the patient sitting and gently leaning forward

Question 3

If persistent bleeding despite pressure for 5-10min

Answer 3

Apply topical vasoconstrictor - soak cotton wool in lidocaine + adrenaline and apply to bleeding area for 5-10min

Question 4

If active bleeding stops and the bleeding point is visible what can you do next?

Answer 4

Precisely cauterise the bleeding point or prominent vessel with silver nitrate stick applied for 1 to 2 seconds

Question 5

Cautions with silver nitrate nasal cautery

Answer 5

Cauterise only 1 nostril at each session (risk of septal perforation if both sides are cauterised at the same time)
Avoid over-cauterisation as this can cause further bleeding and mucosal breakdown which may lead to a septal perforation.

Question 6

Education to provide

Answer 6

Most children will grow out of nosebleeds.

Nose picking may be a cause and should be discouraged.

Pinching the soft part of the nose with thumb and index finger for 5 to 10 minutes usually controls the bleeding.

Question 7

If a patient has epistaxis and is using a steroid nose spray what should you advise?

Answer 7

Stop 2 to 4 weeks to allow healing of the mucosa.

Use opposite hand to administer the nasal spray, i.e. hold spray in right hand to spray in left nostril. This aims the spray away from the nasal septum.

Question 8

Treatment to prevent recurrence of epistaxis?

Answer 8

Fusidic acid ointment BD for 2 to 4 weeks.
Pea-sized amount inside of the tip of both nostrils then gently compress the nasal alae to distribute the ointment.