Epistaxis

Section: Emergency Curriculum: Curriculum, page 29

Classification

• Anterior
  • Kiesselbach’s plexus/Littles area
  • Vascular watershed areas of the nasal septum (medial)
  • Anastomosis of 3 arteries:
    • Septal branch of anterior ethmoidal A
    • Lateral nasal branch of sphenopalatine A
    • Septal branch of the superior labial branch of facial
• Posterior (less common but more serious)
  • Likely caused by posterolateral branches of sphenopalatine artery
  • Or branches of the carotid
  • Requires hospitalisation if having posterior bleed and needing packing

Clinical

• Significance and when to refer
  • Ongoing bleeding that is not settling despite pressure, packing, local agents
  • Haemodynamics
  • On blood thinners or has a coagulopathy

Investigations

• FBC/U+E
• Coagulation studies if on blood thinners, group and hold, cross match if profuse bleeding

Management

• Control of medical factors
• Cease and reverse anticoagulants if possible
• Give first crystalloid followed by blood products if indicated
• Control of haemorrhage escalated in step wise approach
• Anterior
  • ABC
    • If ABC compromised - resuscitate, early ENT referral, OT
    • If ABC ok then…
  • Conservative measures
    • Patient pinches nasal alae together anteriorly and leans forward (prevent blood being aspirated)
    • Give oxymetazoline spray
      • Nasal decongestant with vasoconstriction effect
    • Rhinoscopy to identify source
    • Cautery
      • Chemical - silver nitrate
      • Electrical - bipolar diathermy
  • Anterior nasal packing
    • Nasal tampon soaked with TXA
    • Anterior balloon
    • Gauze
    • Thrombogenic gel or foam - surgicel
  • Bilateral nasal packing
  • If failure then likely posterior
    • Contact ENT
    • Posterior packing via balloon or foley catheter
• Packing
  • Anterior and Posterior
  • Foley catheter or rapid rhino much easier
  • Give 2% lidocaine spray and oxymetazoline spray
  • Soak rapid rhino in sterile water for 30 seconds to allow easy sliding
  • Don’t use saline as it disrupts the action of the carboxymethylated cellulose which promotes thrombosis
  • Different lengths for ant and post - has 2 balloons
  • Insert catheter along floor of nasal cavity until plastic proximal fabric ring lies in the nares
  • Inflate the catheter with air until the pilot cuff is round anf firm.
  • Reassess the pilot cuff at 10 minutes and add more air if needed then secure to cheek