Epistaxis

Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.

Incidence

60% population at some time

6% need medical attention

>90% are anterior septal bleeds-can be controlled in a GP setting

Aetiology

     Local

     Systemic

3 main types of Epistaxis

   1 90 % anterior little area bleed

   2 SPA territory bleed <10% (posterior arterial)

   3 Anterior Ethmoidal bleed

The septum- site of capillary bleeds

Lateral Nasal wall- site of posterior bleeds

Important aspects on Hx

Anterior epstaxis: starts anterior, Unilateral, Common,  may bleed for a long period with no systemic effects, this is capillary bleed- can be managed in the GP practice setting.

Bleeding with systemic conditions as HHT, conditions which affects coagulation- those patients should be packed with Rhino (see below)/ referred to ED, coagulation should be corrected prior to cautery.

HHT patient

Posterior epistaxis: Bleeding tends to start orally and bilateral nasally, tends to be heavy , can stop then start to haemorrhage. This is an arterial bleed from the spheno palatine artery (SPA). May need a posterior pack/ URGENT admission to ED

Post nasal fracture bleed can be from the anterior ethmoidal artery

Controlling Epistaxis

A Have equipment ready, do a mental rehearsal (especially if actively bleeding) 

1  Co phenylcaine spray

2  Adrenaline 1/1000 mixed with 4% xylocaine 1:3 soak a cotton wool strip

3 Nasal suction-if needed

4 Tilly’s nasal packing forceps

6 Nasal speculum-learn how to use it

7 have these set up on a clean surface

And a Head Lamp- use to direct light inside the nose not outside!

B Nasal Prep

Nasal Prep is probably the most important aspect: this will control the bleeding, anaesthetise the nose and reveal the bleeder.

 1 Must use a headlight correctly to direct light inside the nose (not outside), Must learn to use a speculum correctly to expose the septum. If speculum is not available push the tip up as shown, this will give an adequate view to the anterior septum

2 Remove clots -suction if not blow them out

3 Then prep spray: Co phenylcaine spray-this will decongest the mucosa

4 Then place rolled out cotton soaked in prep-further decongest and anaesthetise. Instil this about 5 cm inside the nasal passage-direct posteriorly not upwards -Time-5 mins

Correct way

Wrong Way-pointing upward

C Identification of the bleeder and controlling

Once correctly prepped the bleeding vessel will standout, rest will blanch

This could be cauterised by using silver nitrate on the vessel

Afterwards apply ointment or a dressing-such as surgical with ointment on it

D Cautery vs Packing

Cautery should only be done when a prominent vessel is seen

Consider packing with a Rhinopack if excessive anterior bleeding, not controlled by cautery

If suggestive of a posterior-arterial epistaxis consider packing with a posterior pack or a balloon catheter

E If on Anticoagulants

If anti coagulated these patients should not be excessively cauterised. Prep the nose and put a gentle Rhino and refer to ED

F Bit More on Packing

uncontrolled anterior bleeds are best packed with a Rhio pack

This comes in 5.5 cm size or 7.5 cm size

it has a balloon coved by a gel surface

remove the blue sheath

soak for about 10 seconds the surface becomes gel like

In a prepped nose, insert the pack AP direction (not up) then inflate with air until balloon is firm  

Correct angle of insertion

Foley's is used for a post Haemorrhage

Have the nose prepped

push the foley until tip seen intra orally

warn the patient, then inflate with 10 mls of saline

quickly pull into the nose until the balloon impacts on the post nasal space

Use a clamp to secure the catheter with good anterior traction

note collumela necrosis can occur due to the clamp, hence soft packing should be inserted anteriorly to reduce pressure on the nose

antibiotic cover -to stop toxic shock syndrome

This is a posterior pack (not a catheter). This shows how it compresses the Spheo-Palatine Artery SPA to control a posterior epistaxis