Epistaxis Flashcards
What % of epistaxis is anterior and posterior and what is the anatomic source of the bleeding?
- 90% anterior (Kiesselbach’s plexus – Little’s Area)
- 10% posterior (Sphenopalatine artery)
What is important to ask on history in patients presenting with epistaxis?
- Unilateral or bilateral
- Duration, Severity, Inciting incident
- Frequency, PMHx/FMHx of bleeding disorder
What are 7 potential causes of epistaxis? (TN)
- Mechanical – nose picking, foreign body, trauma (fractures
- Infections – sinusitis (acute and chronic)
- Irritants – smoke, allergens, dry environment
- Medications
- ASA, NSAIDs, anticoagulation
- Nasal drugs (corticosteroids, antihistamines, illicit drugs - cocaine)
- Coagulopathies
- Hereditary – Hemophilia, vWD, etc.
- Diffuse oozing, multiple sites, recurrent
- Acquired – Hypertension, Thrombocytopenia, Liver failure, Renal failure, Hematologic cancers
- Hereditary – Hemophilia, vWD, etc.
- Juvenile Nasopharyngeal Angiofibroma (JNA) – teenage boys with recurrent unilateral epistaxis
- Most common benign tumour of the nasopharynx
- Intranasal neoplasm or polyps – recurrent, unilateral, nasal obstruction
- Benign and malignant
What is the most important information to determine on physical examination in a patient presenting with epistaxis?
- Vitals (Hemodynamic stability)
- Ensure patient is stable if considering massive or prolonged epistaxis
- BP elevation can contribute to prolonged bleeding or oozing
What should be assessed to ensure there is no compromise of in patients with epistaxis?
- Airway – ensure not compromised
- LOOK for posterior drip
When examining the nose of a patient with epistaxis, what should be determined?
- Location of site of bleeding: Anterior vs Posterior
What should be done in the initial management in patients presenting with epistaxis?
- Secure airway and ensure hemodynamic stability
- Consider IV fluids and blood if unstable
- Educate and relieve anxiety of patient and family – can make bleeding worse
- If mom is anxious, child won’t calm down and it won’t resolve
- Have patient blow their nose to dislodge any clots
- Try to localize the source of the bleeding (anterior vs posterior) using headlamp and nasal speculum
What can be done for general control of epistaxis?
- Ask patient to pinch x15 mins anterior aspect of septum (constant firm pressure)
- Do NOT compress nasal bones
- Ice on cheeks and upper lips
- Patient should relax, head forward
- Minimize swallowing blood
- Avoid airway obstruction
When would laboratory investigations be considered in a patient with epistaxis?
- Unstable patient
- Suspicion of a bleeding diathesis – e.g. multiple bleeding sites
- Use of anticoagulation
What laboratory investigations could be performed in a patient with epistaxis if deemed necessary?
- CBC – Hb and Plts
- INR, aPTT
- Group and Screen
- +/- Liver and Renal function (if suspect pathology)
What are reasons to consider admission for monitoring of O2 sats and apneic spells in patients with epistaxis?
- Elderly
- Bilateral anterior nasal packing
- Posterior bleed
- Coagulopathy
- Comorbid conditions such as CAD, severe hypertension or significant anemia
If a patient is on ASA for CAD and has epistaxis, what should they be counselled on?
- Hold ASA use for 1 week
What can be done for anterior epistaxis if initial pinching/pressure is not successful?
- Application of topical agents via cotton pledgets and then direct pressure
- Anesthetic – 4% lidocaine
- Vasoconstrictor – 1:1000 epinephrine or Otrivin (topical decongestant)
What is the first-line topical vasoconstrictor to use for epistaxis? (TN)
- Otrivin (Xylometazoline)
If anterior epistaxis is refractory to the application of topical agents, what can be done?
- Unilateral chemical cautery with silver nitrate for 30 seconds
- Anesthetize area first
- Do NOT work well with active bleeding
- Bilateral septa cautery should be separated by 4-6 weeks to avoid septal perforation
