Epistaxis

Notes written by Dr Ashley Liu

Epistaxis Shownotes

Classification

Keisselbach’s plexus is the anastomosis of three primary vessels – the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery, and the septal branch of the superior labial branch of the facial artery.

Differentials

Nosebleeds are most commonly caused by mucosal trauma or irritation, but persisting nosebleeds can be certainly associated with a number of other conditions. 

Trauma

• Digital trauma (better known as nose picking)
• Dry mucosa
• Foreign body
• Chronic excoriation (Secondary to intranasal drug use)
• Facial trauma

Medical conditions that increase risk for persistent nosebleed

• Anticoagulation – Warfarin
• Bleeding disorders
  • Hereditary haemorrhagic telangiectasia (Olser-Weber-Rendu disease)
  • Von Willebrand’s disease and haemophilia
• Nasal Neoplasm
  • Squamous cell carcinoma, adenoid cystic carcinoma and melanoma
  • Risk factors – South East Asian
• Hypertension

Management

• Primary Survey – ensure the following

• Airway protection – consider repositioning the patient
• Cardiovascular – ensure haemodynamic stability and implement fluid resuscitation including PRBC replacement. Consider anticoagulant reversal agents if required
  • Warfarin – plasma, factor concentrate or vitamin K (slower)
  • Dabigatran – Idarucizumab
  • Anticoagulants that do not have reversal agents – apixaban, rivaroxaban

• Conservative measures – Positioning, Pressure and Oxymetazoline spray 
• Aim to blow nose to rid of clots and blood
• Spray nares twice with oxymetazoline spray (vasoconstrictor)
• Pince the alae tightly against the septum and hold continuously for 10 minutes
• Cauterisation – Chemical or Electrical

• Ensure sufficient topical anaesthetic is applied
• Chemical cautery is performed with silver nitrate sticks. This is done by placing the applicator to a small area surrounding the bleeding site for a few seconds until a white precipitate forms.
  • Avoid excessive cauterisation as this may cause ulceration and perforation.

• Nasal packing – Merocel tampon or Gauze
• Nasal tampon is usually made of Merocel (synthetic open-cell foam polymer)
• Coat the tampon with bacitracin ointment. This may reduce the risk of toxic shock syndrome
• Insert the catheter by sliding it along the floor of the nasal cavity until the plastic proximal ring lies within the nares
• Expand the tampon by infusing it with saline or bacitracin solution
• Nasal packing – Rapid Rhino or other balloon catheters
• Soak the catheter in sterile water for 30 sec. Do not use saline or lubricants as this may impair the fibres
• Insert the catheter by sliding it along the floor of the nasal cavity until the plastic proximal ring within the nares
• Inflate the catheter with air, using a 20mL syringe
• Reassess in 10-15 min

If persisting bleeds, consider bilateral nasal packing.

• ENT referral

An ENT referral is recommended for further inspection and definitive management of uncontrolled bleeds

Preventative measures

Advise the patient

• Avoid drying the mucosa by keeping a humidified environment
• Topical antibacterial (mupirocin) or bacteriostatic (bacitracin) ointment
• Direct nasal sprays away from the septum
• If they have nasal packing remaining in situ, monitor for signs of toxic shock syndrome and consider oral antibiotics as a preventative measure.

References

“Approach to adult with epistaxis” UpToDate; https://www.uptodate.com.acs.hcn.com.au/contents/approach-to-the-adult-with-epistaxis

“Anticoagulants” Clinical Excellence Commission; https://www.cec.health.nsw.gov.au/keep-patients-safe/medication-safety/high-risk-medicines/anticoagulants