THE CLINICAL CHALLENGE
Approximately 60% of the US population will experience epistaxis during their lifetime, with one-tenth of these patients seeking medical attention. Epistaxis occurs in a bimodal distribution, with peaks at age 2 to 10 and 50 to 80 years, and peak incidence occurring among those older than 70. Although rarely a direct cause of mortality, epistaxis can represent management challenges to the emergency provider, especially in elderly patients and in those with underlying medical conditions.
The mucosal lining of the nose is richly vascularized, with blood vessels arising from branches of both internal and external carotid arteries. Kiesselbach plexus, at the anteroinferior portion of the septum, is an anastomosis of branches of the sphenopalatine, greater palatine, anterior ethmoid, and superior labial arteries, and it is the most common site of bleeding in epistaxis. Anterior bleeds are generally less challenging to manage given the ease of accessibility for cauterization, topical treatment, or application of pressure. By contrast, Woodruff plexus, a conglomeration of thin-walled veins on the lateral nasal wall just under the posterior aspect of the inferior turbinate, is much harder to reach. These posterior venous bleeds, accounting for less than 10% of epistaxis cases, are significantly more difficult to identify and manage.
The etiologies of epistaxis are numerous, but in most cases (80%) there is no identifiable cause. Nasal dryness may be a contributing factor in any case of epistaxis. In children, digital trauma is a common cause. Other causes of epistaxis include recent or distant surgery involving the nose or sinuses, vascular lesions, benign or malignant neoplasms, inherited or acquired coagulopathies, anticoagulant use, chronic uncontrolled hypertension, and trauma.
APPROACH/THE FOCUSED EXAM
Initial evaluation of the epistaxis patient focuses on assessing the patient’s airway, breathing, and circulation and determining whether emergent airway management is necessary. In patients with hemodynamic instability or significant ongoing epistaxis, large bore intravenous access should be obtained for fluid resuscitation and a complete blood count drawn to assess for degree of hemorrhage. Type and screen with ABO cross-match should be considered, because transfusions may be necessary, particularly in patients with existing comorbidities and concomitant cardiovascular disease.
A targeted history should be obtained to determine severity, frequency, duration, and laterality of the nosebleed. Underlying etiologic factors such as coagulopathy (eg, hereditary, hepatic impairment, renal insufficiency), malignancy, preceding trauma or surgery, or anatomic abnormalities should be identified to help direct further workup and management. Additionally, a focused review of medications, specifically anticoagulants, antiplatelet agents, and nonsteroidal anti-inflammatory medications, should be performed, because these may require escalation of therapy to achieve hemostasis. Social history including drug (eg, intranasal cocaine) and alcohol use, as well as smoking, are also important to address with the patient.
Particular attention should be paid to a history of endonasal surgical intervention. True posterior arterial bleeds are quite uncommon and usually associated with recent endoscopic surgery, which can expose arteries in the posterior aspect of the sinonasal cavity. Nasal packing may be necessary in this situation as a temporizing or definitive treatment measure, but a recent history of surgical intervention likely warrants ENT consultation, because packing may have negative consequences for surgical outcomes. In the absence of prior endoscopic surgery, a suspected posterior arterial bleed often instead represents a brisk bleed from a more posterior location of the anterior nose.
Anterior epistaxis will often be clinically obvious. In cases of posterior epistaxis, blood may be traveling from the nasopharynx to the oropharynx, resulting in blood being expelled from the mouth. The source might initially be unclear, as upper gastrointestinal (GI) and pulmonary causes of bleeding could present similarly. Posterior bleeding may also involve larger vessels, resulting in large-volume epistaxis that can present from both nares.
Proper preparation and setup are critical for the effective examination of the patient with epistaxis. A headlamp is essential for visualization, because it allows use of both hands during the assessment and intervention. The provider should have a face mask with eye protection, gloves, a nasal speculum (Figure 10.1), and a Frazier suction tip at bedside. Additional materials for epistaxis treatment such as nasal decongestants, cottonoids, absorbable and nonabsorbable packing materials, procoagulants, and silver nitrate should be readily available. An organized approach to epistaxis treatment will include an orderly progression from less invasive to more invasive therapies.
Encourage the patient to sit up and lean forward to avoid swallowing or aspirating blood. Firm pressure should be applied over Kiesselbach plexus by compressing the soft alar regions of the external nose against the anterior septum for a minimum of 10 minutes. A nasal decongestant can be applied to the nose prior to the initiation of pressure. In most cases, bleeding is minor and will stop with pressure alone.
If pressure fails to resolve the epistaxis, the nares should be cleared of clot using a Frazier tip suction before applying a topical vasoconstrictor such as 0.5% phenylephrine hydrochloride or 0.05% oxymetazoline. The solution can be administered as a spray or applied on a cottonoid. Nasal decongestants can help with vasoconstriction to slow bleeding but will also decongest the nose, allowing for a more thorough nasal evaluation, which may facilitate identification of the site of bleeding. Using a headlamp, anterior rhinoscopy may be performed with a nasal speculum to visualize an anterior bleeding point. If identified, the area can be anesthetized with local anesthesia (such as lidocaine or tetracaine applied via cottonoid) prior to being cauterized directly with either chemical cautery (silver nitrate) or electrocautery.
If no source of bleeding can be identified, or if cauterization is unsuccessful, progression to nasal packs may be required. Ideally, unilateral packing is preferred for patient comfort, although there are instances where bilateral nasal packing is required in order to maximize applied pressure. A variety of absorbable and nonabsorbable packing materials are available,1 but absorbable packing materials have been shown to be effective.2 Some materials may require lubrication to make insertion easier. Generally, all nasal packing will be inserted by sliding the pack posteriorly along the floor of the nose, preferably with bayonet forceps (Figure 10.2). Some packing materials may require administration of saline after insertion for expansion. Inflatable packs require introduction of air via syringe to provide gentle, low-pressure tamponade to the bleeding site. It is beyond the scope of this chapter to debate the merits of all individual packing materials available. Absorbable packing material provides the benefit of avoiding the rebleeding often seen with removal of nonabsorbable packing. Nonabsorbable nasal packing, if employed, should be left in place for 24 to 72 hours before removal. Local complications of nasal packing include sinusitis, septal perforation, and alar necrosis. On removal of packing, the nasal septum should be reexamined and bleeding points cauterized.
Figure 10.2: Nasal packing: packing to control bleeding from the posterior nose. A: Catheter inserted and packing attached. B: Packing drawn into position as catheter is removed. C: Strip tied over bolster to hold packing in place with anterior pack installed “accordion pleat” style. D: Alternative method, using balloon catheter instead of gauze packing. (From Britt LD, Peitzman AB, Barie PS, Jurkovich GJ. Acute Care Surgery. 2nd ed. Wolters Kluwer; 2019. Figure 29.1.)
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