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
If anterior epistaxis is refractory to topical agents and unilateral chemical cautery, what is the next step in management and how is this done?
- Pack nose with ribbon gauze and petroleum jelly or Epistat
- Can back both sides if not controlled unilaterally
- Leave in place for 1-2 days before removal
- Give Clavulin or Cefixime to cover for Staphy (no evidence)
- Pain medication
- Consider absorbable packing material such as Surgicel or Gelfoam
What are 6 potential complications of nasal packing (worse with posterior or >48h)?
- TSST (Toxic Shock Syndrome Toxin) – 1 in 10,000
- Septal hematoma
- Septal abscess
- Sinusitis
- Neurogenic syncope during packing (hypoxemia – naso-pulmonic reflex)
- Pressure necrosis
What are antibiotics recommended for any posterior pack or any pack left for >48 h? (TN)
- Prevent toxic shock syndrome
In which patients is posterior epistaxis more common?
- Older patients
What are 3 situations of epistaxis that may suggest a posterior cause?
- Anterior source is not visualized
- Bleeding from both nares
- Continued bleeding despite anterior control
What should be done in the management of posterior epistaxis?
- Consider referral to ENT for posterior packing and admission
- Place posterior pack using a Foley catheter, gauze pack, or Epistat balloon and subsequently, layer anterior packing bilaterally
- Admit to hospital with packs in for 3 to 5 days
What are management options for patients with persistent bleeding from posterior epistaxis?
- Referral to ENT for endoscopy and/or surgical ligation of artery
- Referral to IR for embolization of bleeding vessels
What should patients with epistaxis be advised about once it has resolved?
- Educate about benign nature of nosebleeds to alleviate anxiety
- Often finger trauma, environment or idiopathic
- Ask if they have any specific concerns that can be addressed
- Acutely: no heavy lifting, no bending over and no heavy blowing
- Educate how to control nosebleeds
- Direct pressure to anterior nose (not bones)
- Hold continually for 15 minutes
- Education about prevention
- Control smoking and humidity
- Vaseline for nasal crusting – use baby finger (not Q-tips)
- NasoGel or Nasal Saline rinse if have a dry nose
- Return to clinic if:
- Not controlled as above
- Recurrent
- Massive
- Lightheaded
- Concerned
