Epistaxis resident survival guide

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

Synonyms and keywords:

Overview

Epistaxis also known as noes bleeding, is a terminology name for bleeding of nose vessels that drains out from nostril (most often) and/or nasopharynx. Epistaxis is often stop easily but sometimes it's an ENT emergency which can be critical if appropriate action does not occur. Kiesselbach's plexus is the source of most epistaxis.

Causes

Base 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
• Malignant hypertension

Common Causes

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

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Epistaxis according the the [...] guidelines.

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Statement Action Strength

1:The patients needs prompt action

Prompt management At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not.

Recommendation

2:

Nasal compression The clinician should treatactivebleedingforpatientsinneedofpromptmanagementwithfirmsustainedcompressionto thelowerthirdofthenose,withorwithouttheassistanceofthepatientorcaregiver,for5minutesorlonger.

Recommendation

3a:NasalpackingForpatientsinwhombleedingprecludesidentificationofableedingsitedespitenasalcompression,theclinicianshould treatongoingactivebleedingwithnasalpacking.

Recommendation

3b:Nasalpackinginpatientswith suspectedincreasedbleedingrisk

Theclinicianshoulduseresorbablepackingforpatientswithasuspectedbleedingdisorderorforpatientswhoareusing anticoagulationorantiplateletmedications.

Recommendation

4:NasalpackingeducationTheclinicianshouldeducatethepatientwhoundergoesnasalpackingaboutthetypeofpackingplaced,timingofandplan forremovalofpacking(ifnotresorbable),postprocedurecare,andanysignsorsymptomsthatwouldwarrantprompt reassessment.

Recommendation

5:RiskfactorsTheclinicianshoulddocumentfactorsthatincreasethefrequencyorseverityofbleedingforanypatientwithanosebleed, includingpersonalorfamilyhistoryofbleedingdisorders,useofanticoagulantorantiplateletmedications,orintranasal druguse.

Recommendation

6:Anteriorrhinoscopytoidentify locationofbleeding

Theclinicianshouldperformanteriorrhinoscopytoidentifyasourceofbleedingafterremovalofanybloodclot(if present)forpatientswithnosebleeds.

Recommendation

7a:Examinationusingnasal endoscopy

Theclinicianshouldperform,orshouldrefertoaclinicianwhocanperform,nasalendoscopytoidentifythesiteof bleedingandguidefurthermanagementinpatientswithrecurrentnasalbleeding,despitepriortreatmentwithpackingor cautery,orwithrecurrentunilateralnasalbleeding.

Recommendation

7b:Examinationofnasalcavityand nasopharynxusingnasal endoscopy

Theclinicianmayperform,ormayrefertoaclinicianwhocanperform,nasalendoscopytoexaminethenasalcavityand nasopharynxinpatientswithepistaxisthatisdifficulttocontrolorwhenthereisconcernforunrecognizedpathology contributingtoepistaxis.

Option

8:Appropriateinterventionsfor identifiedbleedingsite

Theclinicianshouldtreatpatientswithanidentifiedsiteofbleedingwithanappropriateintervention,whichmayinclude oneormoreofthefollowing:topicalvasoconstrictors,nasalcautery,andmoisturizingorlubricatingagents.

Recommendation

9:NasalcauteryWhennasalcauteryischosenfortreatment,theclinicianshouldanesthetizethebleedingsiteandrestrictapplicationof cauteryonlytotheactiveorsuspectedsite(s)ofbleeding.

Recommendation

10:Ligationand/orembolizationfor persistentnosebleeds

Theclinicianshouldevaluate,orrefertoaclinicianwhocanevaluate,candidacyforsurgicalarterialligationorendovascular embolizationforpatientswithpersistentorrecurrentbleedingnotcontrolledbypackingornasalcauterization.

Recommendation

11:Managementofpatientsusing anticoagulationandantiplatelet medications

Intheabsenceoflife-threateningbleeding,theclinicianshouldinitiatefirst-linetreatmentspriortotransfusion,reversalof anticoagulation,orwithdrawalofanticoagulation/antiplateletmedicationsforpatientsusingthesemedications.

Recommendation

12:Hereditaryhemorrhagic telangiectasia(HHT)identification

Theclinicianshouldassess,orrefertoaspecialistwhocanassess,thepresenceofnasaltelangiectasiasand/ororalmucosal telangiectasiasinpatientswhohaveahistoryofrecurrentbilateralnosebleedsorafamilyhistoryofrecurrentnosebleeds todiagnosehereditaryhemorrhagictelangiectasiasyndrome.

Recommendation

13:Patienteducationand prevention

Theclinicianshouldeducatepatientswithnosebleedsandtheircaregiversaboutpreventivemeasuresfornosebleeds,home treatmentfornosebleeds,andindicationstoseekadditionalmedicalcare.

Recommendation

14:NosebleedoutcomesTheclinicianordesigneeshoulddocumenttheoutcomeofinterventionwithin30daysordocumenttransitionofcarein patientswhohadanosebleedtreatedwithnonresorbablepacking,surgery,orarterialligation/embolization.

Recommendation

Patient with epistaxis

Does the patient need immediate action?

Yes→Volume replacement,airway check, Needs for emergency departement

No

Active Bleeding?

Yes→Nasal compression for≥5 min

NO→Rhinoscopy to identify location of bleeding

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Do's

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Don'ts

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References

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