EPISTAXIS

EPISTAXIS
R1 RONNAKORN
EPISTAXIS (Nosebleed)
• Ruptured blood vessel in nasal mucosa
• accounts for about 1 in 200 emergency room visits
• more common in colder seasons because of
decreased humidity and subsequent drying of the
nasal mucosa.
Patient Evaluation Location
Cause of bleeding Treatment

PATIENT EVALUATION
• The initial management for epistaxis in the ED starts with a rapid
primary survey addressing potential airway or hemodynamic
compromise.
• Identify an anterior or posterior source of acute epistaxis with a
directed history and physical examination.
• History concerning : alcohol, drug, medication use especially NSAID,
anticoagulation, antiplatelet, or aspirin use , history of trauma, prior
head and neck procedures, and a personal and family history of
coagulopathy.
Anterior Epistaxis
• 90% of all nasal bleeding occurs
anteriorly in Kiesselbach’s plexus
AKA “Little’s area”
o Greater palatine artery
o Anterior ethmoid artery
o Sphenopalatine artery
o Septal branch of superior
labial artery
Anterior Epistaxis
• Located on Anteroinferior nasal
septum covered by thin mucosa
• Associated with dryness, irritation

, minor trauma (nose picking )
• visible nasal bleeding, usually

unilateral
Posterior epistaxis
• Originate from Woodruff’s plexus
o Branches of sphenopalatine
artery
o posterior ethmoidal arteries
• Located on inferolateral nasal
cavity
• Associated with atherosclerosis ,
Anticoagulant use
Posterior epistaxis
Clinical features suggestive of a
posterior source
• elderly patients with either
inherited or acquired coagulopathy
• significant amount of hemorrhage
visible in the posterior
nasopharynx, hemorrhage from
bilateral nares,
• epistaxis uncontrolled with either
anterior rhinoscopy or an anterior
pack
TREATMENT
CHOICES OF TREATMENT
• Direct nasal pressure
• Cauterization by chemical cautery or electrical cautery
• Thrombogenic foams and gels and tranexamic acid
• Nasal tampon
• Nasal packing
• Anterior nasal packing
• Posterior nasal packing
• Endoscopic sphenopalatine artery ligation
• External carotid artery ligation
Direct nasal pressure
• ask the patient to blow the nose to expel clots to
prepare mucosa for topical vasoconstrictors.
Instill a topical vasoconstrictor such
as oxymetazoline(iliadin®) or phenylephrine.
• lean forward in the “sniffing” position and pinch
the soft nares between the thumb and the
middle finger for a full 10 to 15 minutes and
breathe through the mouth.
Chemical Cauterization(silver nitrate)
• Consider if 2 attempts at direct pressure have failed in mild
bleeding
• anesthetize the nasal mucosa using three cotton pledgets
soaked in a 1:1 mixture of 0.05% oxymetazoline and
4% lidocaine solution
• gently and briefly (a few seconds) apply silver nitrate
directly to the bleeding site after relatively bloodless field is
achieved
• attempts on the same side of the nasal septum should be
separated by 4 to 6 weeks to avoid perforation
• Don’t
• attempt on both sides of the nasal septum
• proceed in the setting of active hemorrhage due to
washout of substrate
• attempt unless the bleeding vessel is visualized
Electrical Cauterization
• Electrical cautery should be left to the otolaryngologist due to the
risk of septal perforation !
Thrombogenic foams and gels and
tranexamic acid
• Gelfoam® and Surgicel® (oxidized cellulose) are
effective hemostatic agents that can be placed
simultaneously on visualized bleeding mucosa, and
they are bioabsorbable, so removal is not needed.
• Tranexamic (no standardized approach)
• 200 mg(100 mg/mL concentration) atomized
into the affected nostril
• cotton pledget or nasal tampon saturated with
500 mg of tranexamic acid and placed into the
affected nostril
• 500 mg of tranexamic acid diluted with 5ml of
NSS and atomized into the affected nostril
Preformed nasal tampons or sponges
Preformed nasal tampons

or sponges
are made of synthetic
material that expands
after hydration
Preformed nasal tampons or sponges
Anterior Nasal Packing
Anterior nasal packing can be placed if direct

pressure, vasoconstrictors, or chemical cautery are
unsuccessful in controlling epistaxis and if
thrombotic foams and gels are not available.
A variety of nasal balloons or sponges are available,

or an anterior pack created by layering ribbon gauze
in the nasal cavity can be used.
Anterior Nasal Packing
https://drive.google.com/drive/folders/1Ked_6Op0XyM
Rku9oPYTTWNHGog1j2ASY
Posterior Nasal Packing
• If longer posterior-length packs do not work, obtain ENT consultation.
• Posterior packing is associated with higher complication rates,
including pressure necrosis, infection, hypoxia, and cardiac
dysrhythmias, especially in patients with underlying cardiopulmonary
disease
• posterior packing is generally applied as a temporizing measure while
awaiting ENT support
Posterior Nasal Packing
Disposition and Follow-up
• observe >= 1 hrs in ED can D/C if stable
• follow-up within 48 to 72 hours for removal of non biodegradable
packing
• short-term prescription of inhaled vasoconstrictors such
as oxymetazoline for rebleeding.
• patients on warfarin with INR levels in the desired range may
continue medication
• discontinue NSAIDs for 3 to 4 days
Disposition and Follow-up
• If anterior packing with either absorbable or nonabsorbable material
is going to be in place for more than 48 hours, an antibiotic with
staphylococcal coverage such as amoxicillin-clavulanic acid has been
traditionally recommended to prevent infection with Staphylococcus
aureus and possible associated toxic shock syndrome.
• If the packing will be removed in 24 to 36 hours, prophylactic
antibiotics may not be needed
• If the patient requires posterior packing, admission is strongly
advised to monitor for complications.
Clinical Practice Guideline
REFERENCES

EPISTAXIS

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EPISTAXIS

Cause of bleeding Treatment

• Associated with dryness, irritation

• visible nasal bleeding, usually

Preformed nasal tampons

Anterior nasal packing can be placed if direct

A variety of nasal balloons or sponges are available,

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