Epistaxis medical therapy: Difference between revisions

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{{Epistaxis}}
{{Epistaxis}}
'''Editor in Chief''': [[User:Ludi|Liudvikas Jagminas, M.D., FACEP]] [mailto:LJagminas@mhri.org] Phone: 401-729-2419
{{CMG}} ; '''Associate Editor(s)-in-Chief''':[[User:Amir Bagheri|Amir Behzad Bagheri, M.D.]] {{Jose}}
==Medical Therapy==
The flow of blood normally stops when the blood [[coagulation|clots]], which may be encouraged by [[Emergency bleeding control|direct pressure]]  applied by pinching the soft fleshy part of the nose. This applies pressure to [[Little's area]], the source of the majority of nose bleeds and promotes clotting. Pressure should be firm and be applied for at least 10 minutes while keeping the head in the neutral position and spitting out any blood which flows into the mouth. There is no benefit to pinching the bridge of the nose or to tilting the head backwards or forwards. Swallowing excess blood can irritate the stomach and cause vomiting. Local application of an ice pack to the forehead or back of the neck or sucking an ice cube has seen widespread practice, but has been shown to not have any statistically significant effects on nasal mucosal blood flow.<ref>[http://www.ingentaconnect.com/content/bsc/cot/2003/00000028/00000006/art00013 IngentaConnect Efficacy of ice packs in the management of epistaxis<!-- Bot generated title -->]</ref> In the past, it was commonly thought that the ice would help by promoting constriction of local blood vessels and thus reducing blood flow to slow down the bleed.  Do not pack the nose with tissues or gauze. <ref>{{cite web|url=http://www.rush.edu/rumc/page-1098987337863.html|title=Rush University Medical Center|accessdate=2008-03-05}}</ref>


The local application of a vasoconstrictive agent has been shown to reduce the bleeding time in benign cases of epistaxis. The drugs [[oxymetazoline]] or [[phenylephrine]] are widely available in over-the-counter nasal sprays for the treatment of [[allergic rhinitis]], and may be used for this purpose.<ref name="pmid2676467">{{cite journal |author=Guarisco JL, Graham HD |title=Epistaxis in children: causes, diagnosis, and treatment |journal=Ear Nose Throat J |volume=68 |issue=7 |pages=522, 528–30, 532 passim |year=1989 |pmid=2676467 |doi=}}</ref>
==Overview==
Most of the time no action is needed to stop [[epistaxis]]. In active [[bleeding]], nasal compression is the first line strategy to stop bleeding. If [[bleeding]] continues there are other options such as [[cautery]] and [[vasoconstrictive]] agents such as [[oxymetazoline]] or [[phenylephrine]] to control [[bleeding]].


Other products available that promote coagulation include Coalgan (in Europe) or NasalCEASE (in the US).  These are a calcium alginate meshes that are inserted in the nasal cavity to accelerate coagulation.
==Medical Therapy==
If nasal bleeding is active and nasal compression cannot stop the [[bleeding]], there are the following medical options:<ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref> <ref name="KremplNoorily2016">{{cite journal|last1=Krempl|first1=Greg A.|last2=Noorily|first2=Allen D.|title=Use of Oxymetazoline in the Management of Epistaxis|journal=Annals of Otology, Rhinology & Laryngology|volume=104|issue=9|year=2016|pages=704–706|issn=0003-4894|doi=10.1177/000348949510400906}}</ref> <ref name="MontastrucMontastruc2014">{{cite journal|last1=Montastruc|first1=François|last2=Montastruc|first2=Guillaume|last3=Taudou|first3=Marie-Josée|last4=Olivier-Abbal|first4=Pascale|last5=Montastruc|first5=Jean-Louis|last6=Bondon-Guitton|first6=Emmanuelle|title=Acute Coronary Syndrome After Nasal Spray of Oxymetazoline|journal=Chest|volume=146|issue=6|year=2014|pages=e214–e215|issn=00123692|doi=10.1378/chest.14-1873}}</ref> <ref name="KrulewitzFix2019">{{cite journal|last1=Krulewitz|first1=Neil Alexander|last2=Fix|first2=Megan Leigh|title=Epistaxis|journal=Emergency Medicine Clinics of North America|volume=37|issue=1|year=2019|pages=29–39|issn=07338627|doi=10.1016/j.emc.2018.09.005}}</ref> <ref name="DouglasWormald2007">{{cite journal|last1=Douglas|first1=Richard|last2=Wormald|first2=Peter-John|title=Update on epistaxis|journal=Current Opinion in Otolaryngology & Head and Neck Surgery|volume=15|issue=3|year=2007|pages=180–183|issn=1068-9508|doi=10.1097/MOO.0b013e32814b06ed}}</ref>
If these simple measures do not work, then medical intervention may be needed to stop bleeding, possibly by an [[otolaryngology|otolaryngologist (ENT doctor)]].
*General management of patients is important. Stabilizing the patient and treating the specific cause is the basis of management.
In the first instance this can take the form of chemical cautery of any bleeding vessels or packing of the nose with ribbon gauze or an absorbent dressing. Such procedures are best carried out by a medical professional. Chemical cauterization is most commonly conducted using local application of a silver nitrate compound to any visible bleeding vessel. This is a painful procedure and the nasal mucosa should be anesthetized first,  preferably with the addition of topical [[adrenaline]] to further reduce bleeding. If bleeding is still uncontrolled or no focal bleeding point is visible then the nasal cavity should be packed with a sterile dressing, which by applying pressure to the nasal mucosa will tamponade the bleeding point. Ongoing bleeding, despite good nasal packing, is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anesthesia to identify an elusive bleeding point or to directly ligate (tie off) the blood vessels supplying the nose. These blood vessels include the sphenopalatine, anterior and posterior ethmoidal arteries. More rarely the maxillary or [[external carotid artery]] can be ligated. The bleeding can also be stopped by intra-arterial embolization using a catheter placed in the groin and threaded up the [[aorta]] to the bleeding vessel by an interventional radiologist. Continued bleeding may be an indication of more serious underlying conditions.<ref>[http://www.nlm.nih.gov/medlineplus/ency/article/003106.htm MedlinePlus Medical Encyclopedia: Nosebleed<!-- Bot generated title -->]</ref>
*At first [[airway]], [[breathing]] and [[circulation]] should be evaluated.
 
An algorithm for the management of epistaxis is depicted below:<ref name="pmid29345234">{{cite journal| author=Beck R, Sorge M, Schneider A, Dietz A| title=Current Approaches to Epistaxis Treatment in Primary and Secondary Care. | journal=Dtsch Arztebl Int | year= 2018 | volume= 115 | issue= 1-02 | pages= 12-22 | pmid=29345234 | doi=10.3238/arztebl.2018.0012 | pmc=5778404 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29345234  }} </ref>
Chronic epistaxis resulting from a dry nasal mucosa can be treated by spraying [[Saline (medicine)|saline]] in the nose up to three times per day.
{{familytree/start}}
{{familytree | | | | | | | | | | | | | Z01 | | | | |Z01='''[[Epistaxis]]'''<br>Treatment by a primary care physician or emergency physician}}
{{familytree | | | | | | | | | | | | | |!| | | | |}}
{{familytree | | | | | |,|-|-|-|-|-|-| A01 |-|-|-|-|.| |A01=❑ '''Compression of the [[nostrils]]<br>❑ Ice  application to the neck area<br>❑ Upright sitting position<br>❑ Blood to be spat out<br>❑ Take [[blood pressure]], lower if appropriate'''}}
{{familytree | | | | | K01 | | | | | | |!| | | | | K02 | |K01=Patient '''hemodinamically stable''', [[bleeding]] '''stops'''|K02= Patient '''hemodinamically unstable'''}}
{{familytree | | | | | |!| | | | | | | B01 | | | | |!| | |B01=Patient '''hemodinamically stable''', [[bleeding]] '''persists'''}}
{{familytree | |,|-|-| L01 |-|.| | | | |!| | | | | L02 | |L01=❑ 30min observation,<br>❑ [[Antiseptic]] nasal cream|L02=❑ '''Emergency''' transfer to '''ENT''' department<br>❑ '''[[Volume]] replacement'''}}
{{familytree | C02 | | | | | | C03 |~| C01 | | | | |!| | |C02='''[[Bleeding]] stops:'''<br>❑ Discharge patient home<br>❑ Prevent recurrence;<br>❑ Nasal mucosal care <br>❑ No nose-blowing for 7-10 days|C01= '''Emergency referral to otorhinolaryngologist'''|C03= '''[[Bleeding]] resumes'''}}
{{familytree | | | | | | | | | | | | | |!| | | | | |!|}}
{{familytree | | | | | | | | | | | | | Y01 | | | | |!| |Y01='''Anterior [[rhinoscopy]]'''<br>'''[[Endoscopy]]''' if required}}
{{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| |!|}}
{{familytree | | | | | | | | | D01 | | | | | | D02 |!|D01= Source of [[bleeding]] visible, '''anterior'''|D02= Source of [[bleeding]] not visible and/or '''posterior'''}}
{{familytree | | | | | | | | | |!| | | | | | | |!| |!|}}
{{familytree | | | | E00 |-|-| E01 |~| E03 | | E02 |!| | | | | | | | | |E00= '''[[Bleeding]] stops:'''<br>❑ Discharge patient home<br>❑ Prevent recurrence;<br>❑ Nasal mucosal care <br>❑ No nose-blowing for 7-10 days|E01= '''[[Eletrocoagulation]]''' or '''[[silver nitrate]] [[cautery]]''';<br>'''[[Hemostatic gauze]]''' if required|E03= '''[[Bleeding]] persists:'''<br>Nasal packing|E02= '''Nasal packing'''}}
{{familytree | | | | | | | | | | | | | |!|,|-|-|-|-|'| | | | | |}}
{{familytree | | | | | | | | | | | | | K01 | | | | | |K01=Treatment of [[epistaxis]] in the '''ENT department'''}}
{{familytree | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | | | | | | J01 | | J02 | | | J03 | | | | | | | | | |J01= '''[[Bleeding]] stops'''|J02= '''[[Bleeding]] persists, patient fit for [[surgery]]'''|J03='''[[Bleeding]] persists, patient not fit for [[surgery]]'''}}
{{familytree | | | | | | | | | |!| | | |!| | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | M01 | | M02 | | | M03 | | | | | | | | |M01= '''Remove packing after 48h''', '''[[antibiotics]]''' if needed|M02='''Surgical treatment''', usually '''[[endoscopic sphenopalatine ligation]]'''|M03= '''[[Embolization]]'''}}
{{familytree | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | N01 | | N02 | | | | | | | | | | | | |N01= If [[bleeding]] persists, '''embolization'''|N02=If [[bleeding]] persists:<br>Patient fit for [[surgery]] - '''[[surgery]]'''<br> Patient not fit for [[surgery]] - '''[[embolization]]'''|}}
{{familytree/end}}


Application of a topical [[antibiotic]] ointment to the nasal mucosa has been shown to be an effective treatment for recurrent epistaxis.<ref name="pmid11843924">{{cite journal |author=Kubba H, MacAndie C, Botma M, Robison J, O'Donnell M, Robertson G, Geddes N |title=A prospective, single-blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood |journal=Clin Otolaryngol Allied Sci |volume=26 |issue=6 |pages=465–8 |year=2001 |pmid=11843924 |doi=}}</ref>  One study found it to be as effective as nasal cautery in the prevention of recurrent epistaxis in patients without active bleeding at the time of treatment (both had a success rate of approximately 50 percent.)<ref name="pmid10384851">{{cite journal |author=Murthy P, Nilssen EL, Rao S, McClymont LG |title=A randomised clinical trial of antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis |journal=Clin Otolaryngol Allied Sci |volume=24 |issue=3 |pages=228–31 |year=1999 |pmid=10384851 |doi=}}</ref>
'''Medical Therapy:'''


Nosebleeds are rarely dangerous unless prolonged and heavy. Nevertheless they should not be underestimated by medical staff. Particularly in posterior bleeds a great deal of blood may be swallowed and thus blood loss underestimated. The elderly and those with co-existing morbidities, particularly of blood clotting should be closely monitored for signs of [[shock]].
*'''[[Vasoconstrictors]]''' (Use with caution in children and patients with [[glaucoma]], [[Hypertension|HTN]],  [[peripheral vasoconstriction]], [[Cardiac disease|cardiac diseases]] and [[cerebrovascular]] problems):
**Preferred regimen (1): [[Oxymetazoline]] 0.05% [[intranasal]] [[spray]]. In children <6 years just with [[physicians]] suggestion.
**Alternative regimen (1): [[Phenylephrine]] 0.25% [[intranasal spray]]. In children ≥2 years [[Phenylephrine]] 0.125% nasal solution can be used.
**Alternative regimen (2): [[Epinephrine]] 1:100,000 with [[Lidocaine]] 1% ([[Topical]] ).


Recurrent nosebleeds may cause [[anemia]] due to [[iron deficiency]].
*'''[[Antifibrinolytic]]''':
**Preferred regimen (1): [[Tranexamic acid]] ([[Tranexamic acid|TXA]]) ([[Topical]] ). In [[coagulopathy]] and [[Hereditary hemorrhagic telangiectasia|HHT]] patients is preferred.<br />


As a summary; first aid of epistaxis includes:
*'''[[Chemical]] [[cauterization]]''' (At first [[anesthesia]] [[bleeding]] site and limit nasal [[cautery]] to site''':'''
**Preferred regimen (1): [[Silver nitrate]] 25%-75%
**Alternative regimen (1): [[Chromic acid]]
**Alternative regimen (2): [[Trichloroacetic acid]]


* Tilt head forward, apply continuous pressure by pinching nares together to avoid posterior blood drainage (5-10 minutes)
*Some [[Medicine|medicines]] are used to prevent [[epistaxis]]:
* Apply silver nitrate to bleeding vessel (if identified)
**'''[[Emollient]] [[Cream (pharmaceutical)|creams]]:''' Continues using of topical [[emollient]] [[Cream (pharmaceutical)|creams]] is useful to prevent [[epistaxis]].
* Possible blood transfusions
**'''[[Ointment|Ointments]]:''' Continues using of topical [[Ointment|ointments]] is useful to prevent [[epistaxis]]
* Platelet transfusion, [[vitamin K]], fresh frozen plasma, clottin factor replacement for bleeding disorders (if necessary)
* Possible ENT consult


==References==
==References==
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[[Category:Rhinology]]
[[Category:Rhinology]]
[[Category:First aid]]
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[[Category:Injuries]]
[[Category:Injuries]]
[[Category:Needs overview]]

Latest revision as of 14:37, 14 January 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief:Amir Behzad Bagheri, M.D. José Eduardo Riceto Loyola Junior, M.D.[2]

Overview

Most of the time no action is needed to stop epistaxis. In active bleeding, nasal compression is the first line strategy to stop bleeding. If bleeding continues there are other options such as cautery and vasoconstrictive agents such as oxymetazoline or phenylephrine to control bleeding.

Medical Therapy

If nasal bleeding is active and nasal compression cannot stop the bleeding, there are the following medical options:[1] [2] [3] [4] [5]

  • General management of patients is important. Stabilizing the patient and treating the specific cause is the basis of management.
  • At first airway, breathing and circulation should be evaluated.

An algorithm for the management of epistaxis is depicted below:[6]

 
 
 
 
 
 
 
 
 
 
 
 
Epistaxis
Treatment by a primary care physician or emergency physician
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Compression of the nostrils
❑ Ice application to the neck area
❑ Upright sitting position
❑ Blood to be spat out
❑ Take blood pressure, lower if appropriate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient hemodinamically stable, bleeding stops
 
 
 
 
 
 
 
 
 
 
 
 
Patient hemodinamically unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient hemodinamically stable, bleeding persists
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 30min observation,
Antiseptic nasal cream
 
 
 
 
 
 
 
 
 
 
 
 
 
Emergency transfer to ENT department
Volume replacement
 
 
 
 
 
 
 
Bleeding stops:
❑ Discharge patient home
❑ Prevent recurrence;
❑ Nasal mucosal care
❑ No nose-blowing for 7-10 days
 
 
 
 
 
Bleeding resumes
 
Emergency referral to otorhinolaryngologist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anterior rhinoscopy
Endoscopy if required
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source of bleeding visible, anterior
 
 
 
 
 
Source of bleeding not visible and/or posterior
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleeding stops:
❑ Discharge patient home
❑ Prevent recurrence;
❑ Nasal mucosal care
❑ No nose-blowing for 7-10 days
 
 
Eletrocoagulation or silver nitrate cautery;
Hemostatic gauze if required
 
Bleeding persists:
Nasal packing
 
Nasal packing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment of epistaxis in the ENT department
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleeding stops
 
Bleeding persists, patient fit for surgery
 
 
Bleeding persists, patient not fit for surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Remove packing after 48h, antibiotics if needed
 
Surgical treatment, usually endoscopic sphenopalatine ligation
 
 
Embolization
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If bleeding persists, embolization
 
If bleeding persists:
Patient fit for surgery - surgery
Patient not fit for surgery - embolization
 
 
 
 
 
 
 
 
 
 
 
 

Medical Therapy:

References

  1. Tunkel, David E.; Anne, Samantha; Payne, Spencer C.; Ishman, Stacey L.; Rosenfeld, Richard M.; Abramson, Peter J.; Alikhaani, Jacqueline D.; Benoit, Margo McKenna; Bercovitz, Rachel S.; Brown, Michael D.; Chernobilsky, Boris; Feldstein, David A.; Hackell, Jesse M.; Holbrook, Eric H.; Holdsworth, Sarah M.; Lin, Kenneth W.; Lind, Meredith Merz; Poetker, David M.; Riley, Charles A.; Schneider, John S.; Seidman, Michael D.; Vadlamudi, Venu; Valdez, Tulio A.; Nnacheta, Lorraine C.; Monjur, Taskin M. (2020). "Clinical Practice Guideline: Nosebleed (Epistaxis)". Otolaryngology–Head and Neck Surgery. 162 (1_suppl): S1–S38. doi:10.1177/0194599819890327. ISSN 0194-5998.
  2. Krempl, Greg A.; Noorily, Allen D. (2016). "Use of Oxymetazoline in the Management of Epistaxis". Annals of Otology, Rhinology & Laryngology. 104 (9): 704–706. doi:10.1177/000348949510400906. ISSN 0003-4894.
  3. Montastruc, François; Montastruc, Guillaume; Taudou, Marie-Josée; Olivier-Abbal, Pascale; Montastruc, Jean-Louis; Bondon-Guitton, Emmanuelle (2014). "Acute Coronary Syndrome After Nasal Spray of Oxymetazoline". Chest. 146 (6): e214–e215. doi:10.1378/chest.14-1873. ISSN 0012-3692.
  4. Krulewitz, Neil Alexander; Fix, Megan Leigh (2019). "Epistaxis". Emergency Medicine Clinics of North America. 37 (1): 29–39. doi:10.1016/j.emc.2018.09.005. ISSN 0733-8627.
  5. Douglas, Richard; Wormald, Peter-John (2007). "Update on epistaxis". Current Opinion in Otolaryngology & Head and Neck Surgery. 15 (3): 180–183. doi:10.1097/MOO.0b013e32814b06ed. ISSN 1068-9508.
  6. Beck R, Sorge M, Schneider A, Dietz A (2018). "Current Approaches to Epistaxis Treatment in Primary and Secondary Care". Dtsch Arztebl Int. 115 (1–02): 12–22. doi:10.3238/arztebl.2018.0012. PMC 5778404. PMID 29345234.

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