Epistaxis

Background

Pathophysiology

1. 90% anterior
2. Kiesselbach plexus or Little area

Misc

1. Hypertension does not cause NBs but may prlong bleed; rx with analgesia and mild sedation
2. For severe or recurrent NBs or pts on Coumadin, have hepatic or renal dysfxn, consider CBC, Coags, T&S
3. Posterior packing complications: hypoxia, hypercarbia, exacerbation of OSA, aspiration, hypertension, bradycardia, arrhythmias, MI, death

Treatment

1. Apply anterior pressure
2. Start with 4 tongue blades and tape
3. Ice pack
4. Gown up and gown the patient
5. Kidney basin

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

ANTERIOR NB

1. Step 1: Clear nose of blood with suction or have pt blow nose
   1. Identify bleeding source with good light and speculum
   2. Open speculum vertically; rest index finger of speculum hand on bridge of pts nose
   3. If bleeding point cannot be localized, approx depth of bleeding can be localized using small Frazier suction catheter
   4. Place at nares and tilt pts head forward so that the sxn captures all bleeding
   5. Advance catheter posteriorly along the floor of the nose until blood returns from the nares and note depth
2. Step 2:
   1. Afrin spray (topical oxymetazoline): alapha agonist
   2. LET (lido 4%, epi 0.1%, tetracaine 0.4%) applied to cotton ball or gauze and remain in nares for 10-15mins
   3. Lidocaine 4% spray
   4. Topical cocaine HCL 4% or 10%
   5. Inject 0.5-1.0cc 1% lido in epi 1:100,000 with 27 gauge needle
3. Step 3: Cautery
   1. 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.
   2. If dry wet silver nitrate tip first
   3. Roll over area for 5-10s until grey eschar forms
   4. 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
4. Step 4: Nasal packing (if Step 3 fails)
   1. Merocel: (insert after adequate analgesia)
   2. Lubricate the TIP with antibiotic ointment (bacitracin) or surgical lubricant
      1. 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
      2. If the pack doesn’t rehydrate with blood may inject with NS or lido with epi or other vasoconstrictor
      3. Trim as necessary
   3. Epistaxis ballons: after checking balloon integrity lubricate copiously with viscous lidocaine or or water-based lubricant and insert
      1. Inflate balloons slowly; use NS if in place for duration >hours
      2. Rapid Rhino (inflatable balloon covered in carboxymethylcellulose hydrocolloid) that acts as a platelet aggregator and also forms a lubricant upon contact with water
         1. Soak in basin of sterile water for 30 seconds
         2. Inserted along septal floor and parallel to hard palate until fabric ring is well within the naris
         3. Inflate with 20cc syringe with air or NS
         4. Leave in place for 72h
      3. Surgicel or Oxycel (oxidized regenerated cellulose) and Gelfoam (absorbable gelatin foam) encourage platelet formation
         1. Place directly over bleeding site
      4. FloSeal is a biodegradable hemostasis sealant
         1. Works in anticoagulated patients – doesn’t require platelet aggregation
         2. Using forceps, place a moistened piece of gauze over FloSeal matrix for 1-2 minutes to ensure material remains in contact with bleeding tissue
         3. Begins to break down after 3-5days
      5. Thrombin-JMI Epistaxis Kit bovine derived topical thrombin
         1. Tradional packing: Sterile petroleum ribbon 0.5-1cm ribbon.
         2. Cover with abx ointment
         3. Grasp ribbon about 6cm from end with bayonet forceps and insert along floor of nose
         4. Remove speculum and place on top of ribbon and press down
         5. Grab ribbon 4-5cm from nasal alae and place in nose
         6. Once finished make sure both ends are protruding from nose
         7. Cover with gauze and secure with tape

POSTERIOR NB

1. Transpalatal injection of the sphenopalatine artery
   1. Bend a 25-gauge needle at 2.5 cm
   2. Insert needle through the descending palatine foramen
      1. Medial to the upper second molar
   3. Aspirate
   4. Inject 1.5-2.0 ml of 1% lidocaine with epinephrine (1:100,000)
2. Foley catheter (12 or 14F with 30cc balloon) lubricate then advance until tip and balloon are entirely in nasopharynx
   1. Fill the balloon with sterile saline (us 5-10cc) to allow it to be pulled snugly against the posterior nasal choana with anterior traction
   2. Secure in place with umbilical or c-clamp on the catheter
3. Epistat has posterior balloon and anterior Merocel nasal tampon
4. Storz T3100 nasal catheter has separate anterior and posterior balloons
   1. Insert then inflate posterior balloon with 5-10cc NS then pull forward gently until snug; inflate anterior balloon with 15-30cc NS

Aftercare/Disposition

1. 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
2. F/U: stop ASA and NSAIDs for a few days
3. 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
4. If nasal pack, prescribe analgesics, abx (Bactrim, Keflex or Augmentin) and f/u with ENT in 3days
5. Avoid nose blowing, straingig, bending over, sports; nseeeze with mouth open
6. Home humidifiers and saline nasal spray in drier, colder months

Admission

1. Posterior packing: risk of airway obstrxn and subsequent hypoxemia and dysrhythmias
   1. Significant blood loss
   2. Abnormal vital signs
   3. Coagulopathies
   4. Refractory epistaxis
   5. Anterior packing with CHF, COPD

Source

DeBonis 7/09