EM@3AM: Epistaxis

Author: Joshua J. Oliver, MD (EM Attending Physician, San Antonio, TX) and Tracey M. Lyons-White, PA-C (Physician Assistant, Sierra Vista, AZ) // Edited by Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX)  

Welcome to EM@3AM, an emDocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


A 62-year-old male presents holding a bloody wash cloth pinched over his nose spitting blood into a coffee mug.  His wife walks in behind him with a grocery bag full of medications.  Among them you recognize a common blood thinner.

What should you consider, and what are your next steps?


Answer: Epistaxis

Background:

  • Epistaxis affects up to 60% of the population. It has a bimodal distribution, most commonly in those < 10 years and those between 45 and 65 years.1,2
  • Epistaxis can be classified as anterior and posterior, with anterior bleeds accounting for 90% of cases. The vessels most commonly responsible for these bleeds are Kiesselbach’s plexus and the posterolateral branches of the sphenopalatine artery, respectively.3
  • The most common causes of epistaxis is direct trauma (nose picking) and dry air irritating the mucus membranes.
  • Obtaining coagulation studies should not be part of the routine evaluation of epistaxis, as patients rarely require coagulation reversal. One study quotes a rate of reversal of 1.5 per 1000 person-years.4
  • A coagulation panel may be useful for patients taking anticoagulants. Hemoglobin/Hematocrit on CBC may identify those acutely anemic from hemorrhage.4,5

Presentation:

  • Patients will most commonly present with bleeding from one or both nares. Severe bleeding may be associated with symptoms from blood loss (ie chest pain, shortness of breath, syncope, near-syncope, etc).

 Evaluation:

  • Strongly consider putting on personal protective equipment (PPE).
  • It may be difficult to identify the source of bleeding, but an attempt should be made after the patient blows out the existing blood clots and you have suctioned the nose using:
    • Nasal speculum with a light source (with up-down orientation).
    • Wall suction as needed.
  • If there is any sign that the patient has airway compromise, the priority is not controlling the bleeding, but controlling the airway. If that is the case, skip the steps listed below, aggressively suction, consider intubation, and place an emergent consult to ENT and possibly IR.
  • Note that without a fiberoptic scope, it may be difficult to identify a posterior bleed if that is the source.

Management: listed as a stepwise approach in order of increasing invasiveness.

  1. Afrin 1 spray in affected nares followed by at least 10 minutes of direct pressure, along with lidocaine for anesthesia.
  2. Another option is to soak gauze or a nasal tampon in lidocaine with epinephrine and place in affected nares, followed by another 10 minutes of direct pressure. Patients with large nares may require two tampons simultaneously.
    1. Epinephrine provides further vasoconstriction, while the lidocaine provides pain control for anticipated cautery.6
  3. Consider chemical cautery with a silver nitrate stick after asking the patient to blow out any clots and repeating nasal suction.
    1. Bleeding control is accomplished by drawing a circle around the bleeding source with the silver nitrate stick.
    2. Only use this technique if the source of bleeding can be easily visualized with no active hemorrhage.
    3. Do not cauterize both sides of the septum, as it can cause irreversible septal ischemia.
  4. If bleeding continues, consider any of the following as the next step.
    1. An anterior balloon tamponade device.
    2. Hemostatic gels or foams.7,8
      1. Often ENT’s preferred technique. It is as effective as balloon tamponade and causes less trauma on removal and therefore less re-bleeding, but often not available in the ED.
    3. TXA soaked gauze, nasal tampon, or balloon tamponade device.9
      1. TXA most commonly comes in a solution concentrated at 100mg/ml. Soak your chosen device in 5 mL (500mg) of this TXA before inserting.
    4. If bleeding controlled, observe for 2-3 hours and discharge with packing in place and instructions to follow up with ENT or their primary care provider within 2-3 days.
      1. Prophylactic antibiotics: This remains a controversial topic. While educating patients on the signs and symptoms of toxic shock syndrome (TSS) should be included as part of return precautions, the risks of adverse reaction to antibiotics very likely outweigh the risk of TSS.10
    5. If bleeding remains uncontrolled at this point, it should be assumed that the patient has a posterior bleed, and a posterior balloon tamponade device should be placed. Following placement, the patient should be admitted to monitor their airway as the device will likely protrude into the posterior pharynx and increase the risk of aspiration.  The patient should also be evaluation by ENT as an inpatient.

 

From Hanson’s Anatomy:

Please see this post from Emergency Medicine Cases for further epistaxis pearls, as well as this emDOCs post for more on posterior epistaxis.

 

References:

  1. Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician 2005; 71:305.
  2. Pallin DJ, Chng YM, McKay MP, et al. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med 2005; 46:77.
  3. Tomkinson A, Roblin DG, Flanagan P, Quine SM, Backhouse S. Patterns of hospital attendance with epistaxis. Rhinology. 1997;35(3): 129
  4. Thaha MA, Nilssen EL, Holland S, Love G, White PS. Routine coagulation screening in the management of emergency admission for epistaxis—is it necessary?  Journal of Laryngology and Otolaryngology 2000;114(1):38.
  5. Nitu IC, Perry DJ, Lee CA. Clinical experience with the use of clotting factor concentrates in oral anticoagulation reversal.  Clinical and Laboratory Haematology.  1998;20(6):363.
  6. Katz RI, Hovagim AR, Finkelstein HS, Bocci RV, Poppers PJ. A comparison of cocaine, lidocaine with epinephrine, and oxymetazoline for prevention of epistaxis on nasotracheal intubation.  Journal of Clinical Anesthesiology.  1990;2(1):16.
  7. Mathiesen RA, Cruz RM. Prospective, randomized, controlled clinical trial of a novel matrix hemostatic sealant in patients with acute anterior epistaxis.  Laryngoscope.  2005;115(5):899.
  8. Vaiman M, Segal S, Eviatar E. Fibrin glue treatment for epistaxis.   Rhinology. 2002;40(2):88.
  9. Kamhieh Y, Fox H. Tranexamic acid in epistaxis: a systemic review.  Clincal Otolaryngology.  2016 Dec;41(6):771-776.
  10. Lange JL, Peedem EH, Stringer SP. Are prophylactic systemic antibiotic necessary with nasal packing?  A systemic review.  American journal of rhinology and allergy.  2017 Jul 1;31(4):230-247.

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