Epistaxis resident survival guide

Epistaxis Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D.

Synonyms and keywords: Epistaxis approach, An approach to epistaxis, Nose bleeding approach

Overview

Epistaxis, also known as nose bleeding, is terminology for bleeding of the nose vessels that drain from the nostrils (most often) and/or nasopharynx. Epistaxis often stops easily but can be an ENT emergency, and may be critical if appropriate action does not occur. Kiesselbach's plexus is the source of most epistaxis.

Causes

Based on the cause and severity of Epistaxis, it can be life-threatening.

Life Threatening Causes

Life-threatening causes of epistaxis include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Haemophilia
• Congestive heart failure
• ITP
• Leukemia

Common Causes

• Local trauma
• Acute sinusitis
• Allergic rhinitis
• Anticoagulation
• Aspirin
• Chronic rhinitis
• Chronic sinusitis
• Barotrauma
• Cocaine
• Common cold
• Foreign bodies
• Nose-picking
• Neoplasia

There is not enough evidence that hypertension is a risk factor for epistaxis. The role of lowering blood pressure to control and prevent epistaxis remains controversial.

Diagnosis

Shown below is an algorithm summarizing the diagnosis of epistaxis according to North America Clinical Practice Guideline.

Patient with Epistaxis? Take a complete medical history ❑ Recurrent bleeding? ❑ Using anticoagulant or antiplatelet medications? ❑ Recent trauma or surgery ❑ Vascular abnormalities ❑ Family history of epistaxis ❑ Allergies ❑ Cancer ❑ Other underlying diseases -Check the following labs in severe bleeding or with possibility of coagulopathy: ❑ CBC ❑ PT ❑ PTT

Trauma

Coagulopathy

Vascular abnormalities

Others

Trauma is the most frequent cause of epistaxis(17%) ❑ Digital trauma ❑ Facial trauma ❑ Foreign body insertion ❑ Septal perforation ❑ Barotrauma ❑ Illicit drugs

❑ Using Anticoagulants or Antiplatelet medications ❑ ITP* ❑ von Willebrand disease ❑ Leukemia ❑ Other medications causing coagulopathy

❑ HHT** ❑ Congestive heart failure ❑ Granulomatosis with polyangitis

❑ Sinusitis ❑ Allergies ❑ Septal deviation ❑ Neoplasia in situ ❑ Renal failure ❑ Uremia ❑ Hepatic dysfuction ❑ Idiopathic ❑ Infection

• ITP = Immune thrombocytopenic purpura
• HHT = Hereditary Hemorrhagic Telangiectasia

This algorithm developed and modified according to Epistaxis of Emergency Medicine Clinics of North America and Clinical Practice Nosebleed (Epistaxis) Guideline. This guideline was published in the January 2020 issue of the American Academy of Otolaryngology-Head and Neck Surgery.

Treatment

Shown below is an algorithm summarizing the treatment of epistaxis according to The American Academy of ENT guidelines.

Patient with Epistaxis

First assess ABC*

Need of Immediate Action?

Yes→ : ❑ Assess Airway ❑ Hemodynamic stability ❑ Needs for emergency setting

No

Active Bleeding ?

Yes→Nasal compression for≥5 min

No

Bleeding resume

Bleeding Controlled

Rhinoscopy to identify location of bleeding

Risk factor Assessment : ❑ Assess HHT ** ❑ Bilateral bleeding ❑ Epistaxis history in Family

Bleeding site identified?

Rhinoscopy to identify location of bleeding

Yes→ Three options: ❑ 1= Lubricants ❑ 2= Topical vasoconstrictors ❑ 3= Nasal cautery

No

Bleeding site Identified

Bleeding site not identified

Decision for Nausal Cautery?

Anesthesia bleeding site and limit Nasal cautery to site

Yes→ Anesthesia bleeding site and limit Nasal Cautery to site

No

Bleeding controlled

Bleeding resume

Rist factor assessment

Suspected Bleeding site HHT ** or on anticoagulants?

Patient education and prevention

NO→Non absorbable or Absorbable packing(Preferred in children)

Yes→Absorbable packing

Outcome Assesment

Nasal packing education

Discharge

Bleeding controlled

Bleeding resume

Patient use anticoagulant or antiplatelet medications

Patient doesn't use anticoagulant or antiplatelet medications

Patient Education and prevention

Life treatening Nose bleeding ?

Outcome Assement

Yes→ Evaluate need for or risk of discontinuation Anti-Coag/Anti-Platelet medications

No

Discharge

Bleeding controled

Bleeding resume

Evaluate candidency for embolization or surgical arterial ligation

Appropriate intervention which may include embolization, Surgery, Additional Nasal packing or Cautery

Patient Education and Prevention

Outcome Assesment

Discharge

• ABC= Airway, Breathing, Circulation
• HHT = Hereditary Hemorrhagic Telangiectasia

This algorithm developed and modified according to Epistaxis of Emergency Medicine Clinics of North America and Clinical Practice Nosebleed (Epistaxis) Guideline. This guideline was published in the January 2020 issue of the American Academy of Otolaryngology-Head and Neck Surgery.

Do's

• Assess ABC

• Absorbable packs are preferred in children because the removal of the nonabsorbable pack is difficult.
• Before Nasal cautery anesthetize the bleeding area and limit cauterization just to the bleeding site.
• Remove blood clots before rhinoscopy.
• Educate patients and their caregivers about preventive methods for epistaxis.

Don'ts

• Discontinue anticoagulant medications or reverse anticoagulation before cost-benefit assessment.

• Give additional dose of anticoagulant in active bleeding.
• After nasal packing don't educate the patient or caregiver about nasal packing sustenance.

References