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.
References:
Dr Christopher Chin and his informative talk
http://rebelem.com/topical-txa-in-epistaxis/
https://emergencymedicinecases.com/ent-emergencies/
https://lifeinthefastlane.com/epistaxis/
This post was copyedited by Kavish Chandra @kavishpchandra