EPISTAXIS

EPISTAXIS – Etiology, Diagnostic Evaluation and Management

The purpose of the nose is to warm and humidify the air that we breathe in. The nose is lined with many blood vessels that lie close to the surface where they can be injured and bleed. Epistaxis is defined as bleeding from the nostril, nasal cavity, or nasopharynx. Nosebleeds are due to the bursting of a blood vessel within the nose

ETIOLOGY

• Dry, heated, indoor air, which dries out the nasal membranes and causes them to become cracked or crusted and bleed when rubbed or picked or when blowing the nose
• Dry, hot, low-humidity climates, which can dry out the mucus membranes
• Colds (upper respiratory infections) and sinusitis, especially episodes that cause repeated sneezing, coughing, and nose-blowing
• Vigorous nose-blowing or nose-picking
• The insertion of a foreign object into the nose
• Injury to the nose or face
• Allergic and nonallergic rhinitis (inflammation of the nasal lining)
• Use of drugs that thin the blood (aspirin, nonsteroidal anti-inflammatory medications, warfarin and others)
• High blood pressure
• Chemical irritants (e.g. cocaine, industrial chemicals, others)
• Deviated septum
• Tumors or inherited bleeding disorders
• Facial and nasal surgery

Nosebleeds can be divided into 2 categories based on the site of bleeding: anterior or posterior

• Anterior hemorrhage: the source of bleeding is visible in about 95% of cases – usually from the nasal septum, particularly Little’s area which is where Kiesselbach’s plexus forms (an anastomotic network of vessels on the anterior portion of the nasal septum)
• Posterior hemorrhage: this emanates from deeper structures of the nose and occurs more commonly in older individuals. Nosebleeds from this area are usually more profuse and have a greater risk of airway compromise

DIAGNOSTIC EVALUATION

History

• Determine if blood is running out of the nose and one nostril (usually anterior) or if blood is running into the throat or from both nostrils (usually posterior)
• Ask about trauma (including nose picking)
• Note family or past history of clotting disorders or hypertension
• Note whether there has been previous nasal surgery
• Discuss medication – especially, warfarin, aspirin
• Enquire about any facial pain or otalgia – these may be presenting signs of a naso-pharyngeal tumor
• In young male patients ask about nasal obstruction, headache, rhinorrhoea and anosmia – signs of juvenile nasopharyngeal angiofibroma

Investigation

• Coagulation studies and blood typing
• Quite marked anemia can result but a hematological malignancy may also be revealed

MANAGEMENT

Initial assessment – first aid

• Resuscitate the patient (if necessary) – remember the ABCD of resuscitation
• Ask the patient to sit upright, leaning slightly forward, and to squeeze the bottom part of the nose (NOT the bridge of the nose) for 10-20 minutes to try to stop the bleeding. The patient should breathe through the mouth and spit out any blood or saliva into a bowl. An ice-pack on the bridge of the nose may help.
• Monitor the patient’s pulse and blood pressure
• If bleeding has stopped after this time proceeds to inspect the nose, using a nasal speculum, consider cautery
• If the history is of severe and prolonged bleeding, get expert help and watch carefully for the signs of hypovolemia

Cautery

• Nasal cautery is a common treatment of epistaxis. A caustic agent such as silver nitrate or an electrically charged wire such as platinum is used to stop bleeding in the nasal mucous membrane
• Chemical cautery of the visible blood vessels on the anterior part of the nasal septum is the most popular treatment method for idiopathic recurrent nosebleeds
• Carefully examine the nasal cavity, looking for any bleeding points, which can usually be seen on the anterior septum – either an oozing point or a visible clot. Note whether there is any pus, suggesting local bacterial infection
• Blowing the nose decreases the effects of local fibrinolysis and removes clots, permitting a clearer examination. Applying a vasoconstrictor before examination may reduce hemorrhage and help locate the bleeding site. A topical local anesthetic reduces pain from examination and nasal packing
• Apply a silver nitrate cautery stick for ten seconds, working from the edge and moving radially-never on both sides of the septum at the same session
• Topical application with 0.5% neomycin + 0.1 % chlorhexidine cream or with Vaseline petroleum jelly is an alternative topical treatment
• If bleeding continues, packing may be considered
• A topical application of injectable form of tranexamic acid has been shown to be better than anterior  nasal packing in the initial treatment of idiopathic anterior epistaxis
• It may be necessary to ligate the splenopalatine artery endoscopically, or occasionally the internal maxillary artery and ethmoid arteries, or perform endovascular embolization of the internal maxillary artery, when packing fails to control a life-threatening hemorrhage. Ligation of the external carotid artery is the last resort.

COMPLICATIONS OF PACKING

• Anosmia
• Pack falling out and continued bleeding
• Breathing difficulties and aspiration of clots
• Posterior migration of the pack, causing airway obstruction and asphyxia
• Perforation of the nasal septum or pressure necrosis of cartilage

Follow these steps to stop a nosebleed in emergency when you are alone

• Relax
• Sit down and lean your body and your head slightly forward. This will keep the blood from running down your throat, which can cause nausea, vomiting and diarrhea
• Breathe through your mouth
• Use a tissue or damp washcloth to catch the blood
• Use your thumb and index finger to pinch together the soft part of your nose. Make sure to pinch the soft part of the nose against the hard bony ridge that forms the bridge of the nose. Squeezing at or above the bony part of the nose will not put pressure where it can help stop bleeding
• Keep pinching your nose continuously for at least 5 minutes before checking if the bleeding has stopped. If your nose is still bleeding, continue squeezing the nose for another 10 minutes
• You can spray an over-the-counter decongestant spray, such as oxymetazoline into the bleeding side of the nose and then applies pressure to the nose
• WARNING: these topical decongestant sprays should not be used over the long term
• Once the bleeding stops, do not bend over, strain or lift anything heavy and do not blow, rub or pick your nose for several days

NURSING MANAGEMENT

Provide nursing interventions to control bleeding

• Have the client sit upright, breathe through the mouth, and refrain from talking
• Compress the soft outer portion of the nares against the septum for 5 to 10 minutes
• Instruct the client to avoid nose-blowing during or after the episode
• If pressure does not control bleeding, prepare to assist the health care provider in inserting an anterior packing or posterior packing as appropriate
• Keep scissors and a hemostat handy to cut the strings and remove the packing in the event of airway obstructions

Provide ongoing assessment to monitor for bleeding

• Inspect for blood trickling into the posterior pharynx
• Observe for hemoptysis, hematemesis and frequent swallowing or belching
• Instruct the client not to swallow but to spit out any blood into emesis basins
• Monitor the client’s vital signs

Provide oral and written instructions for treatment and prevention

• Discuss ways to prevent epistaxis, including avoiding forceful nose-blowing, straining, high altitudes and nasal trauma
• Instruct the client to have adequate humidification to prevent drying of nasal passages
• Instruct the client on the proper way to stop bleeding
• Instruct the client not to put anything up the nasal passages
• Instruct the client to contact a health care provider if the bleeding does not stop