Epistaxis
The level of evidence supporting management options for epistaxis is poor, consisting mostly of reviews and "how I do it" reports - Jeremy Prager
image by: Ammar Hassan
HWN Suggests
ENT Emergencies Pearls, Pitfalls, Tips and Tricks
Step 1: Visualize the bleed
Ensure proper orientation up-down orientation of nasal speculum (see image). If bleeding, ask pt to blow nose gently to clear clots.
Step 2: Anesthetize
Apply cotton pledget with 1:1 mix of oxymetazoline (Dristan or Afrin) & lidocaine, which may be more effective than cocaine (& less side effects), using bayonet forceps. Leave in place for 5–10 minutes with the nose *firmly* clamped.
Step 3: Cauterize
Remember eye and face protection, as silver nitrate causes sneezing. Cauterize dry edges of bleeding site (ie around the site, not on it), for 10–15 seconds maximum.…
Resources
TXA Superior to Packing for Epistaxis, and Patients Like It Better
15-cm cotton pledget soaked in the injectable form of TXA (500 mg in 5 mL). The most difficult aspect of the approach (at least in our EDs) is coordinating with the pharmacy to attain the injectable TXA, but otherwise there is little downside to adding TXA to your nosebleed armamentarium. If I ever get cracked in the honker again and need epistaxis care, I'll be asking for TXA.
Do Patients with Epistaxis Managed by Nasal Packing Require Prophylactic Antibiotics?
The available evidence does not defend the routine use of prophylactic antibiotics in patients who require nasal packing for epistaxis. In patients with immunosuppression, they should be considered.
The Emergency Department Management of Posterior Epistaxis
Let’s discuss a few key points about the management of posterior epistaxis...
The Times they are a Changin' for TXA in Epistaxis?
We would have tweaked their conclusions to say “In select patients (majority taking anticoagulant medication) presenting to an ED with atraumatic epistaxis that is uncontrolled with simple first aid measures and the application of a topical vasoconstrictor, 200mg-400mg of TXA applied in the bleeding nostril on a cotton wool dental roll is no more effective than placebo at controlling bleeding and reducing the need for anterior nasal packing”.
Foley Catheter to Stop Nosebleed???
Once inserted so the catheter can be seen in the back of the mouth, inflate balloon with saline. After inflating the foley balloon, pull the foley catheter back out as if to take the foley catheter out. However, given the foley balloon is inflated, it will snug up in the back of the nose such that it can't be taken out.
Mastering Minor Care: Management of Epistaxis
Spray oxymetazoline (Afrin) in the suspected naris to induce vasoconstriction. Depending on your institution, 4% cocaine hydrochloride solution (Numbrino) may also be available for use which can also be utilized in lieu of Afrin to assist with vasoconstriction.
Pediatric Epistaxis
Most epistaxis resolves with appropriate placement of nasal pressure. Have the child tilt their head forward and apply continuous pressure to anterior nasal alae for 5-10 minutes.
ENT Emergencies Pearls, Pitfalls, Tips and Tricks
There is no evidence that hypertension causes nosebleeds. Usually high BP results from pain or anxiety. Our experts recommend treating these symptoms to manage hypertension in epistaxis patients.
Rapid Rhino
Rapid Rhino consists of an outer layer of carboxycellulose that promotes platelet aggregation, with an inflatable balloon that compresses the nasal cavity upon inflation tamponading the bleeding site. Rapid Rhino have been shown to be as effective as nasal tampons and allow for superior patient comfort on insertion and removal.
ALiEM
Knowledge of the pearls, pitfalls, and troubleshooting tips around managing nosebleeds often can be the difference between a frustrating versus straightforward ED stay for patients.
ETMCourse
Patients with facial trauma (even relatively minor nasal trauma or un-displaced nasal fractures) can lacerate the posterior ethmoidal artery. This commonly bleeds a lot, and then stops when the vessel spasms, and then re-bleeds (often through your packing) when the spasm relaxes. This requires operative repair, so refer intermittent heavy bleeders to ENT early.
Life in The Fastlane
Nasal packing can lead to serious infection (Toxic shock syndrome), most of literature and ENT specialist recommend prophylactic antibiotics, until evidence supports or refutes this practise its most probably best practise to follow this and treat with broad spectrum antibiotics.
MDedge
The level of evidence supporting management options for epistaxis is poor, consisting mostly of reviews and "how I do it" reports. In addition, the majority of literature is written about adult patients, who experience the majority of epsitaxis requiring physician intervention.
Introducing Stitches!
Your Path to Meaningful Connections in the World of Health and Medicine
Connect, Collaborate, and Engage!
Coming Soon - Stitches, the innovative chat app from the creators of HWN. Join meaningful conversations on health and medical topics. Share text, images, and videos seamlessly. Connect directly within HWN's topic pages and articles.
