Epistaxis: Difference between revisions

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==Pathophysiology==
==Background==
[[File:Arteries of the Nose.jpg|thumb|The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds).]]
[[File:PMC3895177 270 2013 776 Fig1 HTML.png|thumb|Schematic arterial supply of the sinonasal cavity. The majority of the posterior epistaxis episodes arise from the septum. The arterial branches involved in epistaxis include the internal maxillary artery, the facial artery, and the ophthalmic artery.]]


===Types===
*Anterior
**90% of nosebleeds
**Occur in anterior septum (Kiesselbach plexus)
**Can visualize with anterior rhinoscopy
*Posterior
**10% of nosebleeds
**Occur from nasopalatine branch of sphenopalatine artery
**Cannot visualize without endoscope


90% anterior
===Risk factors===
*Digital trauma (i.e. nose-picking)
*Rhino[[sinusitis]]
*[[Anticoagulant]]/[[antiplatelet]] use
*[[Facial trauma|Trauma]]
*Neoplasia, [[juvenile nasopharyngeal angiofibroma]]
*Dried mucus membranes
*[[Hypertension]] (does not cause bleeding but prolongs existing bleeding)
*Osler-Weber-Rendu ([[Hereditary hemorrhagic telangiectasia]])


Kiesselbach plexus or Little area
===Essential Equipment===
*Light source
*Nasal speculum
*Suction
*Airway equipment
*Packing or constrictive devices


==Clinical Features==
[[File:Young child with nosebleed, smiling cropped.jpg|thumb|Anterior nosebleed after trauma in pediatric patient.]]
*Epistaxis
**Anterior: more likely from one nares
**Posterior: more likely from two nares


==Treatment ==
==Differential Diagnosis==
*[[Facial trauma]]
*[[Coagulopathy]]
*Nasal tumor
*[[Juvenile Nasopharyngeal Angiofibroma (JNA)]]
*[[Hemophilia]]
*Arteriovenous malformation


==Evaluation==
===Anterior versus posterior hemorrhage===
*Assume posterior if measures to control anterior bleeding fail
*Posterior bleeding associated with:
**[[Coagulopathy]]
**Significant hemorrhage visible in posterior nasopharynx
**Sensation of blood dripping down throat
**Hemorrhage from bilateral nares
**Epistaxis uncontrolled with either anterior rhinoscopy or anterior pack


Apply anterior pressure
==Management==
[[File:BleedingNose.jpg|thumb|Demonstration of direct nasal pressure.]]
''Proceed down a stepwise fashion from pressure to vasoconstriction and topical devices to packing while considering risk factors that initiated the event. When initially visualizing, place the patient in the "sniffing position” with the patient slightly leaning forward. Use the speculum in the superior-inferior orientation to avoid septal trauma.  Evaluate for polyps, masses, trauma, and bleeding sources.<ref>Barnes ML, Spielmann PM, White PS. Epistaxis: a contemporary evidence based approach. Otolaryngol Clin North Am. 2012 Oct;45(5):1005-17. PMID: 22980681</ref>''


Start with 4 tongue blades and tape
===Direct Nasal Pressure===
#Have patient blow nose or use suction to expel clots
#Instill topical vasoconstrictor ([[oxymetazoline]] or [[phenylephrine]])
#Have patient apply direct pressure over cartilaginous area of nasal bridge (not the bony area)
#*Can use 2 tongue depressors taped together on one end to create a makeshift device to pinch the nose
#*Attempt direct pressure for at least 20 minutes before moving to additional modalities
#Patient must lean forward to avoid blood draining down nasopharynx thus preventing desired tamponade


Ice pack
===Chemical Cauterization===
''Generally only effective if acute bleeding has stopped and friable site of bleeding can be adequately visualized.  Less effective in acute hemorrhage''
*Usually Kesselbach's plexus for anterior bleeds
#Anesthetize with cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
#Once bloodless field obtained, place silver nitrate just proximal to bleeding source
#*Leave on for a few seconds at most
#*Never cauterize both sides of the septum at one go (risk of septal perforation)
#*[https://www.nejm.org/doi/full/10.1056/NEJMvcm2020073 Video of silver nitrate cauterization].


===Thrombogenic Foams===
#Apply Gelfoam or Surgicel on visualized bleeding mucosa
#These materials are bioabsorbable so removal/antibiotics not needed


Gown up and gown the patient
===Anterior Nasal Packing===
''Only use if all of the above have failed''
#Rapid Rhino
#*Soak balloon with water (NOT saline) and insert along the floor of the nasal cavity
#*Inflate slowly with air (NOT saline or water) until the bleeding stops
#Merocel
#*Absorbent nasal tampon
#*Coat tampon with water-soluble antibiotics ointment and insert along floor of nasal cavity
#*If tampon has not expanded within 30s of placement, irrigate it in place with NS
#*Moisten three times per day with saline or water until removal
#Traditional Packing
#*Apply ribbon gauze in accordion-like manner


Kidney basin
===Posterior Nasal Packing===
''90% of epistaxis is anterior.  Only consider posterior packing if all of the above have failed.''
*Associated with higher complication rates (pressure necrosis, infection, hypoxia)
**Temporizing measure while awaiting ENT support
*Consider nasal block as posterior packing is often very uncomfortable
*All posterior packing should be accompanied by anterior packing
*Rapid Rhino-rocket 7.5 cm +.  Also a dual chamber 9 cm packing available.  Inflate posterior then anterior baloons
*Foley catheter with 30-cc balloon if dedicated posterior packing not available
*#Lubricate with topical antibiotic
*#Advance transnasally until visualized in posterior oropharynx
*#Inflate balloon with 7cc of saline; retract 2-3cm until lodged in post nasopharynx
*#Inflate with additional 5-7cc of saline to complete the pack
*Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.


===[[Tranexamic acid]]===
''*The NoPAC trial showed no difference in anterior packing rates with or without topical [[TXA]]. Higher quality evidence than prior studies.<ref>Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (Nopac): randomized controlled trial. Annals of Emergency Medicine. 2021;77(6):631-640.</ref>''
*500mg [[TXA]] applied to topical foam or non-absorbable packing and inserted into nares.<ref>Zahed R. et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial.Am J Emerg Med. 2013 Sep;31(9):1389-92</ref>
**Injectable form of tranexamic acid (500mg/5mL), not the dilute form
**Can consider adding Epinephrine to non-absorbable packing to assist with vasoconstriction


Stepwise approach - if successful do not proceed to next step...
==Disposition==
 
===Anterior Epistaxis===
*Consider checking hemoglobin to ensure no significant blood loss anemia
 
*Discharge after 1 hour of observation
ANTERIOR NB
*Patients on Warfarin with therapeutic INR may continue medication
 
*Discontinue [[NSAIDs]] for 3-4 days
Step 1: Clear nose of blood with suction or have pt blow nose
*Possible [[amoxicillin-clavulanate]] if anterior packing was placed as prophylaxis for bacterial sinus infection or [[Toxic shock syndrome]] although no robust evidence base<ref>Cohn B. Are prophylactic antibiotics necessary for anterior nasal packing in epistaxis? Ann Emerg Med. 2015 Jan;65(1):109-11</ref>
 
*ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
Identify bleeding source with good light and speculum
*Admit if bilateral packing, symptomatic [[anemia]], or anemia requiring [[transfusion]]
 
Open speculum vertically; rest index finger of speculum hand on bridge of pts nose
 
If bleeding point cannot be localized, approx depth of bleeding can be localized using small Frazier suction catheter
 
Place at nares and tilt pts head forward so that the sxn captures all bleeding
 
Advance catheter posteriorly along the floor of the nose until blood returns from the nares and note depth
 
 
Step 2:
 
Afrin spray (topical oxymetazoline): alapha agonist
 
LET (lido 4%, epi 0.1%, tetracaine 0.4%) applied to cotton ball or gauze and remain in nares for 10-15mins
 
Lidocaine 4% spray
 
Topical cocaine HCL 4% or 10%
 
Inject 0.5-1.0cc 1% lido in epi 1:100,000 with 27 gauge needle
 
 
Step 3: Cautery
 
Chemical cautery: silver nitrate for mild active bleeding or after bleeding has stopped (only one side of septum) cauterize on surrounding tissues first then upon source.
 
If dry wet silver nitrate tip first
 
Roll over area for 5-10s until grey eschar forms
 
 
NosebleedQR: nonprescription powder of hydrophilic polymer and potassium salts – forms a crust. Load onto an applicator swab and apply firmly to site b/g pinching nose for 15-20s
 
 
Step 4: Nasal packing (if Step 3 fails)
 
Merocel: (insert after adequate analgesia)
 
Lubricate the TIP with antibiotic ointment (bacitracin) or surgical lubricant
 
Insert with vertical orientation into nose at 45˚ 1-2cm then grasp merocel with bayonet forceps and rotate to horizontal plane and push all the way
 
If the pack doesn’t rehydrate with blood may inject with NS or lido with epi or other vasoconstrictor
 
            Trim as necessary
 
 
Epistaxis ballons: after checking balloon integrity lubricate copiously with viscous lidocaine or or water-based lubricant and insert
 
            Inflate balloons slowly; use NS if in place for duration >hours
 
 
Rapid Rhino (inflatable balloon covered in carboxymethylcellulose hydrocolloid) that acts as a platelet aggregator and also forms a lubricant upon contact with water
 
            Soak in basin of sterile water for 30 seconds
 
Inserted along septal floor and parallel to hard palate until fabric ring is well within the naris
 
            Inflate with 20cc syringe with air or NS
 
            Leave in place for 72h
 
 
Surgicel or Oxycel (oxidized regenerated cellulose) and Gelfoam (absorbable gelatin foam) encourage platelet formation
 
            Place directly over bleeding site
 
 
FloSeal is a biodegradable hemostasis sealant
 
            Works in anticoagulated patients – doesn’t require platelet aggregation
 
Using forceps, place a moistened piece of gauze over FloSeal matrix for 1-2 minutes to ensure material remains in contact with bleeding tissue
 
            Begins to break down after 3-5days
 
 
Thrombin-JMI Epistaxis Kit bovine derived topical thrombin
 
 
Tradional packing: Sterile petroleum ribbon 0.5-1cm ribbon.
 
Cover with abx ointment
 
            Grasp ribbon about 6cm from end with bayonet forceps and insert along floor of nose
 
            Remove speculum and place on top of ribbon and press down
 
            Grab ribbon 4-5cm from nasal alae and place in nose
 
            Once finished make sure both ends are protruding from nose
 
            Cover with gauze and secure with tape
 
 
POSTERIOR NB
 
Foley catheter (12 or 14F with 30cc balloon) lubricate then advance until tip and balloon are entirely in nasopharynx
 
            Fill the balloon with sterile saline (us 5-10cc) to allow it to be pulled snugly against the posterior nasal choana with anterior traction
 
            Secure in place with umbilical or c-clamp on the catheter
 
 
Epistat has posterior balloon and anterior Merocel nasal tampon
 
 
Storz T3100 nasal catheter has separate anterior and posterior balloons
 
            Insert then inflate posterior balloon with 5-10cc NS then pull forward gently until snug; inflate anterior balloon with 15-30cc NS
 
 
==Aftercare/Disposition==
 
 
Observe for 1 hour after control of bleed no matter which treatment; encourage the pt to walk or perform other things that they would do at home
 
F/U: stop ASA and NSAIDs for a few days
 
If rx with cautery, Vaseline or a similar moisturizing agent should be applied liberally in the nose 3x/day for 7-10d to promote healing of friable mucosa and superficial vessels
 
If nasal pack, prescribe analgesics, abx (Bactrim, Keflex or Augmentin) and f/u with ENT in 3days
 
Avoid nose blowing, straingig, bending over, sports; nseeeze with mouth open
 
Home humidifiers and saline nasal spray in drier, colder months
 
Admission:
 
Posterior packing: risk of airway obstrxn and subsequent hypoxemia and dysrhythmias
 
            Siginificant blood loss
 
            Abnormal vital signs
 
            Coagulopathies
 
            Refractory epistaxis
 
            Anterior packing with CHF, COPD
 
 
==Misc==
 
 
Hypertension does not cause NBs but may prlong bleed; rx with analgesia and mild sedation
 
For severe or recurrent NBs or pts on Coumadin, have hepatic or renal dysfxn, consider CBC, Coags, T&S
 
Posterior packing complications: hypoxia, hypercarbia, exacerbation of OSA, aspiration, hypertension, bradycardia, arrhythmias, MI, death
 
 
==Source ==
 
 
DeBonis 7/09


===Posterior Epistaxis===
*Admission to telemetry is strongly advised
*Posterior packing causes vagal stimulation, increasing risk of [[dysrhythmia]] and bronchoconstriction


==Complications==
*Recurrent unilateral epistaxis has been described in association with malignancy <ref>Primary malignant melanoma of the nose: a rare
cause of epistaxis in the elderly. [http://ageing.oxfordjournals.org/content/34/6/653.full.pdf?origin=publication_detail PDF]</ref><ref>Kaposiform hemangioendothelioma arising in the ethmoid sinus of an 8‐year‐old girl with severe epistaxis [http://sbccp.netpoint.com.br/arquivos/HN_08-2006_kaposiform_hemangioendothelioma.pdf PDF]</ref>
*[[Toxic Shock Syndrome]]


==See Also==
*[[In-Training Exam Review]]


==References==
<references/>
[[Category:ENT]]
[[Category:ENT]]
[[Category:Symptoms]]

Latest revision as of 19:49, 26 April 2023

Background

The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds).
Schematic arterial supply of the sinonasal cavity. The majority of the posterior epistaxis episodes arise from the septum. The arterial branches involved in epistaxis include the internal maxillary artery, the facial artery, and the ophthalmic artery.

Types

  • Anterior
    • 90% of nosebleeds
    • Occur in anterior septum (Kiesselbach plexus)
    • Can visualize with anterior rhinoscopy
  • Posterior
    • 10% of nosebleeds
    • Occur from nasopalatine branch of sphenopalatine artery
    • Cannot visualize without endoscope

Risk factors

Essential Equipment

  • Light source
  • Nasal speculum
  • Suction
  • Airway equipment
  • Packing or constrictive devices

Clinical Features

Anterior nosebleed after trauma in pediatric patient.
  • Epistaxis
    • Anterior: more likely from one nares
    • Posterior: more likely from two nares

Differential Diagnosis

Evaluation

Anterior versus posterior hemorrhage

  • Assume posterior if measures to control anterior bleeding fail
  • Posterior bleeding associated with:
    • Coagulopathy
    • Significant hemorrhage visible in posterior nasopharynx
    • Sensation of blood dripping down throat
    • Hemorrhage from bilateral nares
    • Epistaxis uncontrolled with either anterior rhinoscopy or anterior pack

Management

Demonstration of direct nasal pressure.

Proceed down a stepwise fashion from pressure to vasoconstriction and topical devices to packing while considering risk factors that initiated the event. When initially visualizing, place the patient in the "sniffing position” with the patient slightly leaning forward. Use the speculum in the superior-inferior orientation to avoid septal trauma. Evaluate for polyps, masses, trauma, and bleeding sources.[1]

Direct Nasal Pressure

  1. Have patient blow nose or use suction to expel clots
  2. Instill topical vasoconstrictor (oxymetazoline or phenylephrine)
  3. Have patient apply direct pressure over cartilaginous area of nasal bridge (not the bony area)
    • Can use 2 tongue depressors taped together on one end to create a makeshift device to pinch the nose
    • Attempt direct pressure for at least 20 minutes before moving to additional modalities
  4. Patient must lean forward to avoid blood draining down nasopharynx thus preventing desired tamponade

Chemical Cauterization

Generally only effective if acute bleeding has stopped and friable site of bleeding can be adequately visualized. Less effective in acute hemorrhage

  • Usually Kesselbach's plexus for anterior bleeds
  1. Anesthetize with cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
  2. Once bloodless field obtained, place silver nitrate just proximal to bleeding source

Thrombogenic Foams

  1. Apply Gelfoam or Surgicel on visualized bleeding mucosa
  2. These materials are bioabsorbable so removal/antibiotics not needed

Anterior Nasal Packing

Only use if all of the above have failed

  1. Rapid Rhino
    • Soak balloon with water (NOT saline) and insert along the floor of the nasal cavity
    • Inflate slowly with air (NOT saline or water) until the bleeding stops
  2. Merocel
    • Absorbent nasal tampon
    • Coat tampon with water-soluble antibiotics ointment and insert along floor of nasal cavity
    • If tampon has not expanded within 30s of placement, irrigate it in place with NS
    • Moisten three times per day with saline or water until removal
  3. Traditional Packing
    • Apply ribbon gauze in accordion-like manner

Posterior Nasal Packing

90% of epistaxis is anterior. Only consider posterior packing if all of the above have failed.

  • Associated with higher complication rates (pressure necrosis, infection, hypoxia)
    • Temporizing measure while awaiting ENT support
  • Consider nasal block as posterior packing is often very uncomfortable
  • All posterior packing should be accompanied by anterior packing
  • Rapid Rhino-rocket 7.5 cm +. Also a dual chamber 9 cm packing available. Inflate posterior then anterior baloons
  • Foley catheter with 30-cc balloon if dedicated posterior packing not available
    1. Lubricate with topical antibiotic
    2. Advance transnasally until visualized in posterior oropharynx
    3. Inflate balloon with 7cc of saline; retract 2-3cm until lodged in post nasopharynx
    4. Inflate with additional 5-7cc of saline to complete the pack
  • Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.

Tranexamic acid

*The NoPAC trial showed no difference in anterior packing rates with or without topical TXA. Higher quality evidence than prior studies.[2]

  • 500mg TXA applied to topical foam or non-absorbable packing and inserted into nares.[3]
    • Injectable form of tranexamic acid (500mg/5mL), not the dilute form
    • Can consider adding Epinephrine to non-absorbable packing to assist with vasoconstriction

Disposition

Anterior Epistaxis

  • Consider checking hemoglobin to ensure no significant blood loss anemia
  • Discharge after 1 hour of observation
  • Patients on Warfarin with therapeutic INR may continue medication
  • Discontinue NSAIDs for 3-4 days
  • Possible amoxicillin-clavulanate if anterior packing was placed as prophylaxis for bacterial sinus infection or Toxic shock syndrome although no robust evidence base[4]
  • ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
  • Admit if bilateral packing, symptomatic anemia, or anemia requiring transfusion

Posterior Epistaxis

  • Admission to telemetry is strongly advised
  • Posterior packing causes vagal stimulation, increasing risk of dysrhythmia and bronchoconstriction

Complications

See Also

References

  1. ↑ Barnes ML, Spielmann PM, White PS. Epistaxis: a contemporary evidence based approach. Otolaryngol Clin North Am. 2012 Oct;45(5):1005-17. PMID: 22980681
  2. ↑ Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (Nopac): randomized controlled trial. Annals of Emergency Medicine. 2021;77(6):631-640.
  3. ↑ Zahed R. et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial.Am J Emerg Med. 2013 Sep;31(9):1389-92
  4. ↑ Cohn B. Are prophylactic antibiotics necessary for anterior nasal packing in epistaxis? Ann Emerg Med. 2015 Jan;65(1):109-11
  5. ↑ Primary malignant melanoma of the nose: a rare cause of epistaxis in the elderly. PDF
  6. ↑ Kaposiform hemangioendothelioma arising in the ethmoid sinus of an 8‐year‐old girl with severe epistaxis PDF
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