Epistaxis Management in the ED – 3 Step Method | Department of Emergency Medicine

Epistaxis Management

Resident Clinical Pearl (RCP) – December 2018

Luke Taylor R3 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. Kavish Chandra

It’s 0300 and you are on a solo night shift when a 76 year old male with blood dripping out of both nares is brought into an examining room. It looks a little more profuse than what you saw on Stranger Things last month, but you are also wondering how to best tackle this very common emergency problem

History

-Laterality, duration, frequency

-Estimated blood loss, presence of any clots?

-Inciting factors such as trauma or coagulopathy

-Past medical history, especially hypertension, clotting disorder, HHT

-Medications such as anticoagulants or anti-platelets

Physical examination

-Have patient blow nose or use suction to clear clots

-Do not try and visualize until decongestion complete

-Visualize with nasal speculum for site of bleeding. If an anterior bleed, most commonly the bleeding site will be Little’s area (Figure 1)

-See below for management if patient’s ABCs stable. If unstable be prepared to secure airway and call for help – ENT/interventional radiology

Figure 1. Nasal vascular anatomy, adapted from https://www.juniordentist.com/what-is-littles-area-or-kiesselbachs-area-and-the-arteries-in-it.html.

Management

-Get IV access, draw CBC and coagulation profile when indicated

-Treat as unstable until proven otherwise

Pearls

Apply ice to the hard palate (popsicles, ice in the mouth) to reduce nasal blood flow up to 25%
TXA in patients on anti-platelets (primarily aspirin) results in faster cessation of bleeding
Ducanto suction in future -> SALAD technique – Ducanto-bougie intubation for large bleeds
Only reverse anticoagulants if absolutely necessary – “local problem, local solution”

Three Step Approach to Epistaxis

1. Visualize and decongest

Have patient blow their nose to clear all clots
Visualize nasal cavity and oropharynx now and with each reassessment for source of bleeding. Don’t forget to wear mask and use a headlamp
Soak cotton balls or pledgets in lidocaine with epinephrine and 500mg of tranexamic acid
Pack nose with soaked cotton and replace clamp for 10 mins

2. Cauterize

Remove clamp and packing
Area should be well blanched and anesthetized
Visualize plexus and cauterize proximal to bleeding area for 10 sec max AND never both sides of septum (higher risk of septal perforation)
If successful and bleeding ceases on reassessment, apply surgicel wrapped around a small piece of surgifoam to create a “dissolvable sandwich”and discharge home

3. Tamponade

Apply unilateral nasal packing (Rapid Rhino, Merocel, etc)
Reassess in 10 mins, visualizing oropharynx for continued bleeding
If stops, can discharge home with packing in place and follow up in ED or ENT clinic in 48hrs for removal. No antibiotics required in immunocompetent patients.
If continues to bleed, move the patient to a higher acuity area and apply bilateral nasal packs

When to call ENT

If bilateral nasal packing bleeding continues, assume posterior bleed and initiate resuscitation, draw labs (CBC, coagulation profile, cross-match if not already done). Reverse known coagulopathy and consult for OR or embolization.