Epistaxis

1. Epistaxis

2. Epistaxis • Very common • Usually self limiting • Rarely massive bleeding can be fatal

3. Epistaxis - objectives • To understand the causes and predisposing factors • To consider assessment and management • To review complications

4. Epistaxis • Is bleeding from the nose caused by damage to blood vessels of nasal mucosa • Anterior (80-90%), Little’s area anterior nasal septum – Keisselbach plexus of vessels • Posterior from branches of sphenopalatine artery in posterior nasal cavity

5. Epistaxis - prevalence • 60% of population • 6% seek medical attention • Peaks – 2-10 years greater than 45 years – posterior epistaxis more common in older people • Under 2 years rare and may be associated with injury or underlying serious illness

6. Local causes - trauma • Nosepicking • Nasal fractures • Septal ulcers / perforation • Foreign body • Blunt trauma e.g. falls

7. Local causes - inflammation • Infection • Allergic rhinosinusitis • Nasal polyps

8. Other local causes • Topical drugs-cocaine, nasal decongestants • Vascular –hereditary haemorrhagic telangiectasia • Wegenersgranulomatosis • Post-operative – ENT, max fax, ophthalmic

9. Other local causes • Benign tumours – angiofibroma • Malignant tumours – squamous cell • Nasal oxygen

10. General causes • Hypertension • Atherosclerosis • Increased venous pressure from mitral stenosis • Alcohol • Environmental – temperature, humidity, altitude

11. General causes- haematological • Thrombocytopaenia • Platelet dysfunction • Leukaemia • Haemophilia • Anticoagulant drugs • Antiplatelet drugs e.g aspirin, clopidogrel

12. Epistaxis - prognosis • Most self-limiting and do not require medical treatment • Transfusion unusual • Massive bleeding rare but can be fatal

13. Management – Acute epistaxis • ABC • resuscitation as required

14. Acute epistaxis –first aid • Lean forward (decreases blood flow through nasopharynx) • Open mouth, spit blood into bowl, minimises swallowing • Pinch soft part of nose for 10-15 minutes CONTINUOUSLY

15. Assessment – history • Duration • Which nostril • Estimated blood loss • Any home management / packing • Previous epistaxis and management • PMH –likely underlying causes

16. History – look for underlying cause • Surgery • Trauma • Symptoms suggestive of tumour • Nasal obstruction • Rhinorrhoea • Facial pain • Facial numbness, double vision

17. History – look for underlying cause • Drugs • FH bleeding disorders • environmental

18. Assessment - examination • ABC • General examination • Local examination • Light source and nasal speculum • Get patient to blow nose ( dark blood or clots likely to be old) • Look for bleeding point ( if bleeding stopped , small red dot < 1mm)

19. Examination • Profuse bleeding from both nostrils with no visible bleeding point on speculum examination suggests posterior bleed

20. Investigations • FBC if heavy or recurrent bleeding or clinically anaemic (often not required) • Coagulation – if on warfarin or bleeding diathesis suspected • Group and save / cross match - if bleeding heavy, shock, severe anaemia

21. Management – topical antiseptic cream • Naseptin (chlorhexidine and neomycin) qds for 10 days • Avoid in peanut allergy – use mupirocin instead • Reduces crusting and vestibulitis • Very useful in young children as cautery inappropriate

22. Management – nasal cautery • Use if first aid unsuccessful, not for young children • Need appropriate expertise and equipment • Blow nose • Anaesthetic spray preferably with vasoconstrictor (eglignocaine and phenylephrine) • Allow 3-4 mins for anaesthetic to work

23. Management – nasal cautery • Identify bleeding point • Apply silver nitrate stick to bleeding point for 3-10 seconds until grey-white colour develops • Only one side of septum to avoid septal perforation • Avoid touching area not requiring treatment

24. After cautery • Dab cauterised area with clean cotton bud to remove chemical or blood • Naseptin or mupirocin cream • Self care advice

25. Self care advice • Avoid blowing or picking nose • Avoid heavy lifting • Avoid strenuous exercise • Avoid lying flat • Avoid alcohol and hot drinks ( cause vasodilation) • If further bleeding unresponsive to first aid measures, return to ED

26. Nasal Packing • If bleeding not controlled • Local anaesthetic and vasoconstrictor • Nasal tampon (merocel) • Inflatable packs (rapid rhino) • Impregnated ribbon gauze – needs specific expertise

27. Nasal packing • Position sitting forward mouth open • Secure pack to cheek • Check no pressure on cartilage around nostril • Check oropharynx for bleeding, may need to pack both nostrils • Admit ENT

28. Complications of nasal packing • Sinusitis • Septal haematoma /abscess (from traumatic packing) • Pressure necrosis (from excessively tight packing) • Toxic shock syndrome (prolonged packing) • Airway obstruction

29. ENT referral • Uncontrolled bleeding • Posterior bleeding • Nasal pack • Significant comorbidities clotting disorder, anaemia • Recurrent with high risk of underlying cause

30. Episataxis - other treatments • Formal packing • Endoscopy and electrocautery • EUA and surgical intervention e.g. Arterial ligation • Radiological arterial embolisation • IV or oral tranexamic acid

31. Recurrent epistaxis • History and examination • Consider underlying cause • Refer children under 2 years for further investigation • Manage with topical antiseptic or nasal cautery • Refer if epistaxis not settled or high risk of serious underlying cause

32. Questions? • Reference – NICE 2010

33. Summary • ABC and resuscitation plus first aid measures • History – and consideration of underlying cause • Examination local /general • Investigation where appropriate • Management • Referral to ENT

34. Thank you