Epistaxis

Pathophysiology

90% anterior

Kiesselbach plexus or Little area

Treatment

Apply anterior pressure

Start with 4 tongue blades and tape

Ice pack

Gown up and gown the patient

Kidney basin

Stepwise approach - if successful do not proceed to next step...

ANTERIOR NB

Step 1: Clear nose of blood with suction or have pt blow nose

Identify bleeding source with good light and speculum

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