Epistaxis…in a Rush

Oh epistaxis. This dreaded entity can be difficult to control, and always manages to rear its ugly head at the end of a busy shift. Its severity can range from mild bleeding to life threatening hemorrhage. In this brief blog post, we will be discussing important considerations in the workup and treatment of epistaxis. You are going to want to keep your nose IN this business.

Background

• most common in ages <10 or >70 years old
• Anterior bleeds
  • More common (90%)
  • Blood supply from Kiesselbach’s plexus
• Posterior bleeds
  • Less common but usually more severe
  • Blood supply from the sphenopalatine artery, which is a terminal division of the internal maxillary artery (which is a branch of the external carotid artery [!])
  • Bleeding into your nose from the external carotid = bad

History and physical

• First and foremost…ABCs
  • If the patient is hypotensive and hemorrhaging blood out of their nare, focus on resuscitation, airway control, etc before moving on to primary survey
• Now that the patient has successfully been resuscitated (cuz we’re awesome ER docs and that’s what we do best amirite) …lets jump to important history and physical pearls
• Duration of bleeding
• On anticoagulation?
• Any recent facial trauma?
• Family history of bleeding disorders? (i.e. von Willebrand disease)
• Risk factors
  • CKD, alcoholism, intranasal cocaine use, HTN, vascular malformations (i.e hereditary hemorrhagic telangiectasia)
  • Chronic O2 use
  • Deviated septum
  • Digital trauma (i.e. nose picking)

Diagnosis

• Clinical diagnosis
• Grab that nasal speculum (and make sure to open cephalad-caudad when inserted into the nare…let’s not damage that septum)
• Get a good look to try and differentiate anterior vs posterior bleeds
• Consider labs if concerned for coagulopathy, large bleeds, unstable patients, or workup of other comorbid disease

Treatment

• If hemodynamically unstable…resuscitate
  • Two large bore IV’s, fluids, blood, etc, etc, etc
• Stable patient
  • Have patient blow nose (if no history of facial trauma) to clear out clots to allow for better visualization
  • Apply a few squirts of a topical vasoconstrictor such as phenylephrine or oxymetazoline (Afrin) then apply direct pressure for 10-15 minutes
    • Nasal clamps can be found in most ENT carts
    • Can also tape together two tongue depressors between ½ to 2/3’s up to depressor to create your own make-shift clamp
  • Chemical cauterization
    • i.e. silver cautery
    • needs to be applied to relatively bloodless field to be able to under the chemical reaction necessary (science!) to allow for effective coagulation
    • only apply to one side of the nare, otherwise can cause septal perforation
    • be nice to your patient and provide some topical anesthesia in the form of lidocaine-soaked cotton pledglets
  • Thrombogenic foams and gels
    • Aka Surgicel or Gelfoam
    • Apply onto visualized bleeding mucosa
  • Anterior nasal packing
    • Aka Merocel
    • Comes in various sizes
    • Coat in antibiotic ointment and insert into affected nare
    • If not available can also use ribbon gauze packing…same concept
  • Anterior epistaxis balloons
    • Aka Rapid Rhino
    • Soak balloon with water, insert into affected nare, then inflate with 10cc of air
      • Do NOT inflate with saline, if the tampon ruptures there is a risk of aspiration of said saline
    • Tape to patients check
  • TXA
    • Evidence for use of TXA in epistaxis is limited
    • Consider TXA in lieu of saline when soaking anterior nasal packing
    • Caution in patients in whom risk of systemic thrombosis is high (i.e. hx of CAD, ischemic stroke, etc)
      • Systemic absorption of intranasal TXA not well characterized
  • Posterior nasal packing
    • i.e. Epistat
      • Has open catheter that allows for air flow
      • Inflate posterior balloon first with 10cc of air
      • Then inflate anterior balloon 
        • can hold up to 30cc of air…but you may not need that much
  • lots of brands available…check the ENT cart in your shop

Disposition and follow up

• if patient is hemodynamically stable and bleeding has stopped, and they passed a period of observation (~1 hour), consider discharge home
• if anterior packing in place, consider course of antibiotics to prevent infection while awaiting ENT follow up
  • i.e. Augmentin
  • some debate here and no clear recommendations
    • consider if you think packing will be in place >48 hours, but might be able to get away without antibiotics if only in place 24-36 hours
• if on anticoagulation and coags are within normal limits, consider resuming anticoagulation
• stop NSAIDs for 3-4 weeks and counsel on supportive measures at home
  • direct pressure and consider discharging home with rx for topical vasoconstrictor (i.e. Afrin)
• posterior packing? Admission strongly recommended for monitoring and ENT consult

Pearls

• avoid using intranasal products if history of facial trauma
  • potential risk to bust right through the cribriform plate and end up intracranial…which is bad
• many products available to help tamponade bleed…tailor approach to your patient
• consider bringing into room with you on initial assessment: nasal clamp, afrin, nasal speculum, and light source

Shout-out to Dr. Mary Naughton on her awesome epistaxis lecture!

Citations:

McGinnis HD. Nose and Sinuses. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw-Hill; Accessed June 18, 2020. https://accessmedicine-mhmedical-com.ezproxy.rush.edu/content.aspx?bookid=1658&sectionid=109387197

MORE RESOURCES!

EMRAP: https://www.emrap.org/episode/epistaxis/epistaxis (review of commonly used epistaxis products)

https://www.emrap.org/episode/c3epistaxis1/c3epistaxis (brief summary of epistaxis management)