Epistaxis (Nose bleed) management

Epistaxis: Bleeding from inside the nose is called epistaxis. It is a  sign not a disease and attempt should always be made to find any local or constitutional cause.

Clinical Presentation

Patient history: Try to control significant bleeding or hemodynamic instability should be your first priority over obtaining a lengthy history. Ask about the duration,  severity of the bleeding, and the nostril of initial bleeding. Also ask about previous nasal bleeding, hypertension, liver, renal or other systemic disease, family history, easy bruising, or prolonged bleeding after minor surgical procedures. Recurrent episodes of nasal bleeding, even if self-limited, should raise suspicion for significant nasal pathology.  Ask about the use of drugs, especially aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs),anticoagulant therapy warfarin, heparin, ticlopidine, and dipyridamole should be noted, as these not only predispose to epistaxis but make treatment more difficult.

 

Physical examination: General physical examination is important and specially note the pulse and blood pressure of the patient for the hemodynamic stability of the patient. If patient is stable then go for nasal examination and other thorough systemic examination.

Causes of epistaxis. It can be divided into

  • Local causes in the nose can be trauma , infection, foreign body, neoplasm of nose and paranasal sinuses, atmospheric changes, deviated nasal septum. In the nasopharynx adenoiditis, juvenile angiofibroma, malignant tumors.
  • General causes include. Cardiovascular system (hypertension, arteriosclerosis, mitral stenosis, pregnancy). Blood disorders (aplastic anemia, leukemia, thrombocytopenia, vitamin K deficiency). Livers diseases can also cause epistaxis. Kidney disease, drugs ( excessive use of salicylates, anticoagulant therapy)
  • Many times the cause of epistaxis is not clear.

 

Sites of epistaxis:

  • Little’s area. In 90% cases of epistaxis, bleeding occur from this site.
  • Above the level of middle turbinate.
  • Below the level of middle turbinate.
  • Posterior part of the nasal cavity
  • Nasopharynx

Classification of epistaxis:

  • Anterior epistaxis: when blood flows out from the front of nose with the patient in sitting position.
  • Posterior epistaxis: Mainly the blood flow back into the throat.

First aid: most of the time bleeding occur from the little’s area and can be easily controlled by pinching the nose with thumb and index finger for about 5 minutes. This compresses the vessels of the little’s area.
Cauterization: this is useful in anterior epistaxis when bleeding point has been located. The area is first topically anaesthetized and the bleeding point cauterized with a bead of silver nitrate or coagulated with electrocautery.
Anterior nasal packing: In case of active anterior epistaxis, nose is cleared of blood clots by suction and attempt is made to localize the bleeding site. In minor bleed, from the accessible sites, cauterization of the bleeding area can be done. If bleeding is profuse and the site of bleeding area is not accessible or difficult to localize, anterior packing should be done. For this use a ribbon gauze soaked with liquid paraffin.
Posterior nasal packing: It is done in patients bleeding posteriorly into the throat.
Endoscopic cauterization: Bleeding point is localized using topical or general anesthesia with a rigid endoscope.it is then cauterized with a malleable unipolar suction cautery or a bipolar cautery. It has limitation when the bleeding is profuse and does not permit localization of the bleeding point.
Elevation of mucoperichondrial flap and submucous resection. In case of recurrent bleeding from the septum, just elevation and then repositioning of mucoperichondrial flap helps to cause fibrosis and constrict blood vessels. SMR operation can be done to achieve the same result or remove any septal spur which is sometime the cause of epistaxis.
Ligation of Vessels.
External carotid: when bleeding is from the external carotid system and the conservative measures have failed, ligation of external carotid artery above the origin of superior thyroid artery should be done.
Maxillary artery: ligation of this artery is done in uncontrolled posterior epistaxis.
Ethmoidal artery: in anterosuperior bleeding above the middle turbinate not controlled by packing, anterior and posterior ethmoidal arteries can be ligated.
8. Transnasal endoscopic sphenopalatine artery ligation (TESPAL): A mucosal flap is lifted in posterior part of lateral nasal wall, sphenopalatine artery is localized and closed with a vascular clip.

9. Embolization: It is done by interventional radiologist through femoral artery catheterization.
General measures in epistaxis:

Make the patient sit up with a back rest and record any blood loss taking place through spitting or vomiting.
Reassure the patient: Mild sedation should be given
Keep check on pulse, BP and respiration.
Maintain haemodynamics. Blood transfusion may be required.
Antibiotics can be given to prevent any other infection like sinusitis.
Investigate and treat the patient for any underlying local or general cause.

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