Epistaxis (Nose Bleed)

Last updated 30.06.13

Definition

-  Acute haemorrhage from nostril, nasal cavity or nasopharynx

 

Features

-  Anterior

-  Most common

-  Usually from nasal septum (Littles area)

-  Internal & external carotid a.

-  Posterior

-  Post nasal cavity or nasopharynx

-  Sphenopalantine a.

-  60% pop suffers, 10% present to ED

 

Littles Area

 

Causes

-  Difficult to Dx cause

-  Bleeding diathesis: prev episodes

-  HTN

-  Familial

-  Anti-coagulation

-  Trauma, broken nose

-  Intranasal steroids

-  URTI

-  Foreign body

-  Nasal polyps

 

DDx

-  Haemoptysis

- Haematemesis (if large)

- Blood dripping from post nasopahrynx = epistaxis

 

Associated S/S

-  Recurrent episodes

-  Nasal pathology

-  Bleeding diathesis

-  Hypotension, shock

-  HTN: ? cause vs effect

 

Ix

-  Vitals: HR, BP: shock

-  FBE

- Hb: anaemia

- Plts: thrombocytopaenia

-  +/- Coags: INR, APTT

-  +/- Cross match

-  Nasal speculum

- 90% bleed visualised in anterior nasal cavity

 

Mx

-  Compression

-  Compress soft tissue against hard septum

-  10min +

-  If severe

-  IV access

-  IV fluids

-  ECG

-  Pulse oximetry

-  BP may be elevated, avoid antihypertensives if significant bleed

-  Nasalate cream (Chlorhexidine + Phenlyephrine) available OTC

-  May be preferable to cautery in children

-  Vasoconstrictors

-  Insert soaked pledgelets

-  4% cocaine OR

-  4% Lidocaine & Adrenaline 1:10,000

-  Leave in place for 10-15min

-  Cautery

-  If bleeding point is identified chemical cautery (post pledglet anaesthesia)

-  Silver nitrate stick rolled over mucosa until grey eshar forms

-  Only one side cauterized at a time to avoid perforation or necrosis

-  Thermal cautery for more aggressive bleeds (under GA)

-  Packing

-  If above unsuccessful pack nose

-  Unilateral if site identified

-  Should commence oral antibiotics

-  Cephalexin 500mg PO QID

-  Rapid Rhino

-  Inflatable cuff inserted into nostril

-  Nasal tampons

-  Coat w water soluble gel

-  Insert until string reaches nostril

-  Tape string to nose & trim ends

-  Moisten w saline to remove

-  Removal of Rapid Rhino or Nasal Tampons after 24-48hrs+

-  Then can commence nasal sprays ie: Fess with Tranexamic acid

 

Nasal Tampon

 

 

 

References