Rosen & Barkin's 5-Minute Emergency Medicine Consult (251 page)

DIAGNOSIS

• Laterality of the bleeding
  
• Intensity and amount of bleeding from the nares
  
• Recurrence of epistaxis and history of prior episodes
  
• Nasal obstruction and the duration of this symptom
  
• Complaints of vomiting or coughing blood
  
• Known tumors or coagulopathy
  
• Unusual bleeding or easy bruising suggests an underlying coagulopathy.
  
• Presence of systemic disease exacerbated by blood loss (coronary artery disease, chronic obstructive pulmonary disease)
  

• Evaluate vitals for hemorrhagic shock
  
• Careful exam for signs of coagulopathy:
  
  • Bruises
    
  • Petechiae and purpura
    
• Nasopharyngeal inspection:
  
  • Anesthetize nasopharynx prior to exam with cotton swab soaked in anesthetic and vasoactive agent.
    
• Attempt to identify bleeding source with nasal speculum
  
• Blood in mouth or oropharynx
  

• Assess stability: Airway compromise, hypovolemia.
  
• Determine source (anterior vs. posterior).
  
• Consider underlying coagulopathy.
  

• Consider for severe bleeding or suspected coagulopathy:
  
  • CBC, type and cross-match, PT/INR, PTT, BUN
    

Direct visualization of nasal mucosa with nasal speculum:

• Pretreat with topical vasoconstricting agent and anesthetic.
  
• Ensure adequate lighting (i.e., headlamp) and suction.
  

• Hematemesis
  
• Hemoptysis
  

• Posterior epistaxis is rare in children; consider further workup for bleeding diatheses.
  
• Consider nasal foreign bodies or neoplasm, such as juvenile angiofibroma or papilloma.
  
• 4 wk of topical antiseptic ointment decreases incidence of recurrent epistaxis.
  

TREATMENT

• Stable patients: Patient should bend forward at the waist; pinch nares closed, and spit out blood rather than swallow it.
  
• Unstable patients:
  
  • Intubation, if airway is compromised
    
  • IV access
    
  • Crystalloid resuscitation, if signs of hypovolemia
    

• Secure the airway in patients who are unconscious, have major facial trauma, or are otherwise at risk of obstruction or aspiration.
  
• Treat hypotension with crystalloids and blood products, if necessary, and ensure adequate IV access.
  

• Universal precautions against blood/fluid contamination
  
• Anterior source:
  
  • Have patient apply direct pressure by pinching nares closed for 15 min. This may control bleeding and assist with visualization.
    
  • If bleeding persists, use bayonet forceps to place cotton pledgets soaked in vasoconstricting and anesthetic agents into affected nares.
    
  • If view is obstructed by blood have patient blow nose, or clear blood from view with irrigation and suction.
    
  • Visualize source of bleeding and cauterize limited area with silver nitrate.
    
  • Consider Gelfoam or Surgicel packing over cauterized site.
    
• Anterior nasal packing:
  
  • Indicated when cautery has failed to control bleeding
    
  • Associated with significant discomfort and infectious risk of sinusitis and toxic shock
    
  • Anterior nasal balloon:
    
    • Check the integrity of the balloons before insertion.
      
    • Cover with water-based lubricant or viscous lidocaine
      
    • Insert the device and inflate it slowly to avoid discomfort.
      
    • Use saline for the inflation if the balloon is to remain in place > a few hours.
      
  • Preformed nasal tampons:
    
    • Adequate anesthesia of the nasal passage should be ensured before placing the tampon.
      
    • Lubricate the tip of the sponge tampon with antibiotic ointment.
      
    • Insert it at a 45° angle ∼1–2 cm into the nasal cavity.
      
    • Rotate the long axis of the tampon into a horizontal plane and push it firmly back into the nasal cavity.
      
    • If the pack does not fully expand from the blood, then use saline to complete the expansion.
      
    • Secure the drawstring to the cheek.
      
  • Petroleum-jelly–impregnated gauze:
    
    • Add an antibiotic ointment to the gauze.
      
    • Ensure that a free end remains outside the nose.
      
    • Place the gauze as far back as possible, starting on the floor of the nose.
      
    • Repeat while securing the placed gauze with the speculum until the nose is fully packed.
      
  • After anterior packing, persistent new bleeding may be a sign of inadequate packing or posterior source.
    
  • Always treat patients with nasal packing with antibiotics to prevent sinusitis and prevent or limit
    Staphylococcus aureus
    infections that can lead to toxic shock syndrome (TSS).
    
• Posterior source:
  
  • Early endoscopic visualization and cautery of bleeding source may prevent need for posterior packing and admission.
    
  • Posterior packing may be accomplished with commercially available devices such as Nasostat or Epistat.
    
  • If commercial packs are unavailable, a Foley catheter may be directed into posterior nasopharynx until the tip visible in mouth. The balloon is then inflated and the catheter retracted until the balloon is lodged in the posterior nasopharynx. The catheter is then held in place by umbilical clamp.
    
  • Posterior pack should not be left in >3 days due to infectious risk. Patient should be admitted and on telemetry while pack in place due to risk of vagal response.
    
• Complications of posterior packing:
  
  • Pressure necrosis of posterior oropharynx (do not overfill balloon)
    
  • Nasal trauma
    
  • Vagal response with reflex bradycardia
    
  • Aspiration
    
  • Infection/TSS
    
  • Hypoxia
    

• Vasoactive solutions:
  
  • 4% cocaine
    
  • 1:1 mixture of 2% tetracaine and epinephrine (1:1,000)
    
  • 1:1 mixture of oxymetazoline 0.05% (Afrin) and lidocaine solution 4%
    
  • Phenylephrine (Neo-Synephrine)
    
• Antibiotics: For use while packing in place.
  
  • Amoxicillin–clavulanate potassium: 250 mg PO q8h
    
  • Cephalexin: 250 mg PO q6h
    
  • Clindamycin: 150 mg PO q6h
    
  • Trimethoprim–sulfamethoxazole: 160/800 mg PO q12h
    

FOLLOW-UP

• Severe blood loss requiring transfusion
  
• Severe coagulopathy that places the patient at risk of further blood loss
  
• Posterior nasal packing: Otolaryngology consult and admission for telemetry, supplemental oxygen, possible sedation, and observation; possible further surgical intervention (e.g., arterial ligation or embolization)
  
• Patients with anterior packing who do not have reliable follow up within 48 hr.
  

Stable patients:

• Use Afrin nasal spray for 2 days.
  
• Lubricate nares with an antibiotic ointment.
  
• Humidify air.
  
• Avoid nose picking.
  
• All patients with nasal packing in place should be prescribed an antistaphylococcal antibiotic (amoxicillin–clavulanate, cephalexin, trimethoprim–sulfamethoxazole) for the duration that the packing remains in place for prevention of both acute sinusitis and TSS.
  

• Refer all patients with packing to a specialist within 48 hr.
  
• Patients with nonvisualized source, suspicious-appearing lesions, recurrent same-side bleeding, or nasal obstruction should be referred to an ORL specialist for an exam to rule out a neoplastic etiology or a foreign body.
  

• Return to ED for bleeding not controlled by pressure, fever, difficulty breathing, or vomiting.
  
• Avoid any nose blowing for 12 hr after the bleeding stops.
  
• Avoid nose picking or putting anything into the nose.
  
• If the bleeding starts again, sit up and lean forward, pinch the soft part of the nose tightly for 10 min without letting go.
  
• Avoid lifting heavy objects or doing too much work right away.
  
• If there is no packing in the nose, put a small amount of petroleum jelly or antibiotic ointment inside the nostril 2 times a day for 4–5 days.
  
• Use a humidifier or vaporizer at home.
  

• Foreign bodies should be suspected in any unilateral nasal bleeding in small children, psychiatric patients, and patients with mental retardation.
  
• Avoid covering anterior nasal balloons with antibiotic ointment, as petroleum-based materials may cause a delayed rupture of the balloon.
  
• Avoid overinflating nasal balloons or placing a pack too tightly, as it can cause necrosis and eschars.
  
• Patients with packings should receive prophylactic antibiotics
  

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