# Epistaxis Management

## Overview

This module describes how to

manage epistaxis

manage epistaxis

Beyond the bleeding nose is a patient who may have other pathology causing the epistaxis e.g. hypertensive urgency or emergency, patients on warfarin with a raised INR, patients with TB and a thrombocytopaenia. These patients need other therapy in addition to the management of the epistaxis.

that does not resolve with direct pressure.

## Indications

1. Epistaxis that does not resolve after 15 minutes

## Contraindications

1. Significant facial trauma—consult otolaryngology

2. Haemodynamic instability

3. Cautery is contraindicated if the source of bleeding cannot be seen

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I’m going to try different ways to stop your nose bleeding.”

### What can my patient expect?

“We will first try to stop the bleeding by pinching your nose for 15 minutes. If it doesn’t work, I will try to find the bleed and stop it with a chemical. This will be uncomfortable, but it will not burn you. If I can’t stop the bleed this way, I will need to pack your nose tightly with gauze and perhaps even a small balloon. This will be very uncomfortable for you, but this kind of bleed must be stopped. You may need to stay in hospital overnight.”

### What is my patient’s role?

“Tell me if you have any allergies, take blood thinners, or have

medical conditions

medical conditions

Patients with renal failure, liver failure, inherited coagulopathies or disseminated intravascular coagulation should be referred to an ENT specialist in addition to the physicians that manage the respective conditions.

. Let me know if you have severe pain or dizziness at any point.”

## Preparation

Prepare a trolley with equipment.

### Documentation

1. Patient notes

### Equipment

1. Non-sterile gloves

2. Alcohol-based hand rub

3. Face & eye protection

4. Emesis basin

5. Linen saver

6. Two tongue depressors

7. Adhesive tape

8. Nasal speculum if available

9. Good light source

10. Silver nitrate sticks

11. 1-2% lignocaine with adrenaline

12. Cotton balls

13. Gauze strip (1.5 m per nostril), preferably in

    petroleum jelly
    petroleum jelly

    Many emergency centres stock gauze already covered with BIPP (Bismuth Iodoform Paraffin Paste) for nasal packing. This is usually what the nursing staff are familiar with.

14. Forceps, preferably Bayonet forceps

15. Foley catheter

16. 10 ml syringe

17. 10 ml sterile water

18. Rapid Rhino
    Rapid Rhino

    if available

19. Gauze

## Site & Positioning

Position the patient sitting upright.

Most epistaxis originates in the anterior nasal cavity, and most anterior epistaxis originates from Kiesselbach’s plexus.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene and don non-sterile gloves.

2. If not done yet, ask the patient to sit forward and pinch the cartilaginous part of their nostrils for 15 minutes. Alternatively, tape two tongue depressors together in the middle to create a nose clip and apply it for 15 minutes.

3. If the bleeding continues, place the emesis basin and linen saver in the patient’s lap to catch blood. Ask the patient to gently blow their nose to remove clots to identify the source of the bleed.

4. Inspect the nasal passages with a light and nasal speculum, and the oropharynx for blood running down the throat.

5. Insert cotton soaked in

   lignocaine with adrenaline
   lignocaine with adrenaline

   You may need to repeat this step periodically during the management process. Beware of cardiac side effects of adrenaline in the middle aged or elderly.

   into the affected nostril for 5-10 minutes, then remove.

6. Inspect the nostril once more. If still bleeding actively and a source is visible, use silver nitrate to cauterise a small area on and around the bleeding point. Roll the stick over the area for up to 5 seconds. Do not cauterise blindly or widely. Only ever cauterise one side of the

   septum.
   septum.

   The septal cartilage receives blood supply from the mucoperichondrium of the mucosa. If both sides are cauterised, the patient may develop a septal perforation.

7. If bleeding actively with no visible source or if silver nitrate failed, place an anterior pack.

8. Anterior pack: Use Bayonet forceps to insert the gauze strip horizontally along the floor of the nose to the back of the nose. Withdraw and grip the gauze strip 7-10 cm from the tip of the nose and insert it again. Continue inserting folds of gauze until the anterior nose is fully packed (± 1.5 m per nostril). Leave a short end outside the nose.

9. If you have access to Rapid Rhino, it is a much easier and less traumatic device to use for epistaxis. Wet it to create a lubricant for insertion and insert along the floor of the nose. Inflate with 7-8 ml of air and then add titrations of 0.5-1 ml at a time to tamponade the bleeding. It will require ongoing titration every few hours, of 0.5-1 ml, as the air diffuses out of the

   balloon.
   balloon.

   If the patient is to be transported by air, inflate the balloon with 5-6ml of water and titrate slowly to tamponade the bleeding.

10. Observe the patient for

    continued bleeding
    continued bleeding

    If bleeding continues, often the gauze will stay free of blood while blood leaks down the patient's throat. If you do not see any bleeding it is important to ask the patient if they are swallowing blood.

    .

11. Dispose of medical waste safely.

12. Record completion of the procedure in patient notes.

13. Patients with a pack need to be admitted for observation and removal after 48 hours. Continued bleeding warrants otolaryngology referral.

## Troubleshooting

The patient is uncooperative.

Try to reassure the patient, and explain why this is necessary. You may need an assistant to help with restraining.

I don’t have access to a Rapid Rhino and the patient is still bleeding.

Remove the anterior pack. Place a

posterior pack

posterior pack

Some evidence suggests that posterior packing does not tamponade bleeding, but may act as a support to improve the anterior pack. Packing the nose tightly with BIPP or Rapid Rhino should eliminate the need for a posterior pack.

by feeding a Foley catheter through the nostril until it is visible in the oropharynx. To avoid gagging, advance no further. Inflate the balloon with 5 ml of water, then retract it until it is firmly wedged in the posterior nose. Inflate with another 5 ml water. Wrap the catheter in gauze where it exits the nose and secure it to the face with tape. Subsequently, place an anterior pack.

## Risks

1. Failure to stop bleeding; haemodynamic instability

2. Airway compromise

3. Nasovagal response
   Nasovagal response

   Posterior packing can stimulate the vagal nerve, leading to fainting, respiratory arrest, or cardiovascular compromise.

4. Nasal abrasions

5. Pressure necrosis and septal perforation

6. Sinusitis and toxic shock syndrome

7. Splash injury to healthcare personnel

8. Rebleeding on pack removal

## References

1. Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020;162(1_suppl):S1-S38. doi:10.1177/0194599819890327

2. Womack JP, Kropa J, Jimenez Stabile M. Epistaxis: Outpatient Management. Am Fam Physician. 2018;98(4):240-245.

3. Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgraduate Medical Journal. 2005;81:309-314.