Author: Dr. Dennis McKinney
Background:
Epistaxis is one of the most common presenting chief complaints in the emergency department, accounting for about 1 in 200 visits. Different algorithmic approaches exist to address epistaxis, with application of intranasal vasoconstrictors usually existing somewhere in between empathetic counseling/clamping and a rhino rocket.
Most intranasal vasoconstrictors have precautions against use in patients with hypertension, however. Given there is a presumed overlay between patients with epistaxis and those with hypertension, is this something we should be worried about?
This study was a double blinded, randomized control study in a single ED to investigate the effects of intranasal vasoconstrictors on blood pressure when treating epistaxis.
Study Question:
Do intranasal vasoconstrictors (epinephrine, phenylephrine, oxymetazoline) result in clinically significant increases in blood pressure when compared to placebo (saline) when treating epistaxis?
Design:
Patients accrued over two years, enrolled and randomized into one of four study arms at discharge from ED.
– 68 patients enrolled total
– Half of cotton ball soaked in randomly assigned drug, placed in anterior naris w/ clip
– BP measurements taken at 5 min intervals for 30 min
Results:
Primary outcome, greatest increase from baseline MAP after medication administration was measured for each study arm.
| Medication | ∆ MAP (95% CI) mm Hg |
| Phenylephrine | 6.4 (3.7 – 9.1) |
| Oxymetazoline | 5.1 (1.3 – 8.8) |
| Lidocaine with Epi | 4.6 (-0.8 – 9.9) |
| Saline | 6.5 (3.7 to 9.3) |
Discussion:
Each of the intranasal vasoconstrictors involved in this study have been associated with hypertensive crises involving pulmonary edema, cardiovascular collapse, and even death. These reports, however, are mostly in the operative setting and involve children or advanced otolaryngologic procedures.
Topical vasoconstrictors are simultaneously first-line treatment for epistaxis and contraindicated in patients with hypertension, even though this contraindication is frequently bypassed in standard practice.
There were no statistically significant effects on blood pressure between any of the vasoconstrictors and placebo. The findings of this study reiterate the appropriateness of bypassing hypertension precautions when utilizing intranasal vasoconstrictors for epistaxis in the ED.
The study was somewhat limited in that it was underpowered, with only 68 patients enrolled. In addition, the study excluded patients with hypertension which is perhpsthe patient population we would care most about in this setting.
Take home point – Bypassing hypertension precautions when utilizing intranasal vasoconstrictors for epistaxis seems to be reasonable, and vasoconstrictors should continue to be utilized in the emergency department for this purpose.
Citation:
- Bellew SD, Johnson KL, Nichols MD, Kummer T, Effect of Intranasal Vasoconstrictors on Blood Pressure: A Randomized, Double-Blind, Placebo-Controlled Trial; J Emerg Med. 2018 Oct;55(4):455-464.
- Pallin DJ, Chng YM, McKay MP, Emond JA, Pelletier AJ, Camargo CA, Jr. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med 2005;46:77–81.
- Chaaban MR, Zhang D, Resto V, Goodwin JS. Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis. Otolaryngol Head Neck Surg 2017;156:81–6.
- Petruson B, Rudin R, Svardsudd K. Is high blood pressure an aetiological factor in epistaxis? ORL J Otorhinolaryngol Relat Spec 1977;39:155–60.