Focus On: Treatment of Epistaxis

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ACEP News 
June 2009
 

By Charles Gilman, M.D.

Learning Objectives

After reading this article, the physician should be able to:

  • Understand the treatment approach to epistaxis.
  • Utilize established techniques and new products available for nosebleeds.
 

Epistaxis is one of the most common ear, nose, and throat emergencies, with an estimated 60% lifetime incidence rate for an individual person. Of this group, approximately 6% seek medical care to stop the bleeding. Epistaxis has a bimodal age distribution, with most cases in children 2-10 years old and adults 50-80 years old. Certain high-risk groups, such as the elderly, require rapid intervention to stem bleeding and prevent further complications.1

The treatment of epistaxis has undergone significant changes in recent years. Gone are the days when an uncomfortable nasal pack is inserted, with rebleeding upon removal several days later fairly common. New packing devices and ingenious hemostatic agents have been developed to provide a variety of effective and well-tolerated treatment options.2

Treatment of any patient with epistaxis starts with ensuring a secure airway and hemodynamic stability. Ninety percent of nosebleeds are anterior and can be controlled by pinching the anterior aspect of the nose. While awaiting physician evaluation, the triage nurse can place a clamping device constructed of four tongue blades secured together by 1-inch tape over Kiesselbach's plexus, the anterior portion of the nasal septum where there is an anastomotic network of vessels. Evaluation and treatment of epistaxis is expedited by having all of the supplies available in the patient's room (see "Epistaxis Box Supplies"). Good lighting, such as a headlight, is essential and keeps both hands free.

The first step in identifying the source of bleeding is to clear the nose of blood either by the patient blowing the nose or by suctioning. Topical oxymetazoline (Afrin) spray alone often stops the hemorrhage. LET solution (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%) applied to a cotton ball or gauze and allowed to remain in the nares for 10-15 minutes is very useful in providing vasoconstriction and analgesia. Lidocaine 4% spray may be substituted. Some clinicians use topical cocaine hydrochloride, which is available in 4% and 10% solutions and has both topical anesthetic and vasoconstrictive effects as a single agent.

Chemical cautery with silver nitrate is performed for mild active bleeding or after bleeding has stopped and prominent vessels identified. Only one side of the septum is cauterized to reduce the risk of perforation. Optimal results occur when the cauterization is started on the surrounding tissues and then upon the source itself. The silver nitrate stick should be rolled over the area for 5-10 seconds until a grey eschar forms, avoiding prolonged use or too much pressure. Silver nitrate works best on a relatively bloodless surface as any blood flow will wash away the silver nitrate before it can act.

An alternative to cautery is NosebleedQR, a non-prescription powder of hydrophilic polymer and potassium salts, which rapidly forms a crust once applied to a bleeding lesion. The powder is loaded onto an applicator swab and applied firmly to the site allowing it to interact with the blood directly. This is followed by pinching the nose or maintaining direct pressure for 15-20 seconds. Cost is less than $10.

Nasal packing has been the next step for persistent bleeding if cautery is unsuccessful or if no obvious site on the septum is visible. Commercially available balloons are simple to use, rapid, and quite effective for anterior bleeds.

The Rapid Rhino is composed of an inflatable balloon coated with a carboxymethylcellulose hydrocolloid compound that acts as a platelet aggregator and also forms a lubricant upon contact with water. After soaking in a basin of sterile water for 30 seconds, the device is inserted along the septal floor and parallel to the hard palate until the fabric ring is well within the naris. Using a 20-mL syringe, inflate the device with air, stopping when the pilot cuff becomes rounded and feels firm when squeezed, similar to placement of an endotracheal tube. Different sizes are available--a 4.5 cm for children, 5.5 cm for anterior epistaxis, and 7.5 cm for posterior bleeds.

Advantages of the Rapid Rhino over traditional compressed foam products include ease of insertion, patient comfort, and minimal rebleeding upon removal.3 Nasal packs are reported to stop bleeding in 60%-80% of cases refractory to pressure and vasoconstrictors. The pack is left in place for 72 hours. At the follow-up visit, the nose is re-inspected, ideally by an otolaryngologist, to exclude any organic pathology that may have accounted for the bleeding.

A variety of hemostatic compounds that do not require extraction are useful for patients with or without coagulopathies. Oxidized regenerated cellulose (Surgicel or Oxycel) and absorbable gelatin foam (Gelfoam) increase clot formation by encouraging platelet aggregation, can conform to irregular surfaces, and provide some degree of tamponade. Place the product directly over the bleeding site.

FloSeal is a biodegradable hemostatic sealant composed of cross-linked gelatin granules and topical human-derived thrombin that is applied as a high-viscosity gel. One of FloSeal's advantages is that it does not require platelet activation, allowing it to function fully even in anticoagulated patients. The product comes in three separate components needing several minutes to mix. A specially designed applicator is used to apply the solution liberally to the bleeding surface. Using forceps, place a moistened piece of gauze over the FloSeal matrix for 1-2 minutes to ensure the material remains in contact with the bleeding tissue. In cases of persistent bleeding, the applicator tip is inserted through the center of the matrix to deliver fresh material as close as possible to the tissue surface.

One study of 70 patients showed FloSeal able to stop 97% of epistaxis within 2 minutes.4 It is safe and better tolerated than packing, and it avoids a return visit, as it begins to break down within 3-5 days. Cost is $1,079.40 for a 6-pack, or $180 per use.

The Thrombin-JMI Epistaxis Kit is a bovine-derived topical thrombin that was released in 2008. It requires mixing of the thrombin powder with the saline diluent prior to use. After it is drawn up in a 5-mL syringe, a special nasal drug delivery device is attached. The contoured tip is inserted into the naris, and the solution is sprayed as a fine mist across the nasal mucosa. Approximately half (2.5 mL) should be used initially and the remainder utilized after 3-5 minutes if bleeding persists. There are no published articles on this product. Cost is $60 per kit.

Anterior packing is often inadequate to control bleeding from the posterior nasal cavity. These bleeds can be difficult to treat and require either balloon insertion or a formal posterior pack. The most commonly used posterior pack is a Foley catheter (size 12 or 14 French), which is lubricated and then advanced until the tip and balloon are entirely in the nasopharynx. The balloon is filled with sterile saline (usually 5-10 cc) to allow it to be pulled snugly against the posterior nasal choana with anterior traction. The Foley is secured by placing an umbilical or c-clamp on the catheter at the level of the nasal ala with padding in between to prevent pressure injury.

An alternative posterior pack, the Epistat or Storz T3100 nasal catheter, has separate anterior and posterior balloons. The device is inserted until the posterior balloon enters the posterior nasal cavity, inflated with 5-10 mL of saline, and then gently pulled forward until snug. The anterior balloon is then filled with up to 15-30 mL of saline. The Epistat II has a posterior balloon and an anterior Merocel nasal tampon. Although quick and easy to place, the balloon packs may not always be successful as they tend to fill in areas of least resistance. The packs also sometimes put severe pressure on the septum and can be quite painful.

The association between hypertension and epistaxis is complicated. Hypertension does not cause epistaxis but may prolong it. Therapy focuses on control of the hemorrhage rather than reduction of the blood pressure. Analgesia and mild sedation are preferable to antihypertensive therapy.

For patients with severe or recurrent hemorrhage or underlying medical conditions, a complete blood count should be performed, as well as a type and screen. In selected patients, such as those taking warfarin or with hepatic or renal dysfunction, coagulation studies are warranted.

No matter the choice of treatment, the patient should be observed for at least 1 hour after control. Encourage the patient to walk or perform other activities that he or she will need to resume when returning home.

Follow-up instructions include stopping aspirin and NSAIDs for a few days. In the patient treated by cautery, Vaseline or a similar moisturizing agent should be applied liberally in the nose three times a day for 7-10 days to promote healing of friable mucosa and superficial vessels. For the patient with a nasal pack, prescribe analgesics for comfort and arrange ENT follow-up in 3 days.

The role of prophylactic systemic antibiotics in patients who have nasal packs is not well established with wide variations in practice. Although studies to date do not directly address the issue, having been done primarily in patients with postsurgical packing, most sources recommend TMP/SMX, cephalexin, or amoxicillin/clavulanic acid to prevent sinusitis and toxic shock syndrome.

All patients requiring a posterior pack should be admitted because of the risk of airway obstruction and subsequent hypoxemia and dysrhythmias. Supplemental oxygen is administered once the pack is placed. Patients who have sustained significant blood loss or who have abnormal vital signs or concerning comorbidities, including coagulopathies, should be hospitalized. Finally, those with refractory epistaxis despite the above measures are admitted for vessel ligation or selective arterial embolization.

In the past several years, there has been a significant expansion in the number of options available to treat epistaxis. Traditional strategies such as nasal packs have been supplemented by the modern technology of hemostatic agents producing less patient discomfort, improved efficacy, fewer complications, and reduced requirement for emergent ENT consultation.

References 

  1. Viehweg T, Rogerson J, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg. 2006; 64:511-8.
  2. Gifford T, Orlandi R. Epistaxis. Otolaryngol Clin N Am. 2008; 41:525-36.
  3. Singer AJ, Blanda M, Cronin K. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Annals of Emergency Medicine. 2005;45(2):134-9.
  4. Mathiasen R, Cruz R. Prospective, randomized controlled clinical trial of a novel matrix hemostatic sealant in patients with acute anterior epistaxis. Laryngoscope. 2005;115:899-902.

Contributors 

Dr. Gilman is an assistant professor in the division of emergency medicine at Medical University of South Carolina, Charleston. Medical Editor Dr. Robert C. Solomon is an attending emergency physician at Trinity Health System in Steubenville, Ohio, and clinical assistant professor of emergency medicine at the West Virginia School of Osteopathic Medicine.

Disclosures

In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and American College of Emergency Physicians policy, contributors and editors must disclose to the program audience the existence of significant financial interests in or relationships with manufacturers of commercial products that might have a direct interest in the subject matter. Dr. Gilman and Dr. Solomon have disclosed that they have no significant relationships with or financial interests in any commercial companies that pertain to this educational activity. "Focus On: Treatment of Epistaxis" has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). ACEP is accredited by the ACCME to provide continuing medical education for physicians. ACEP designates this educational activity for a maximum of one Category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he or she actually spent in the educational activity. "Focus On: Treatment of Epistaxis" is approved by ACEP for one ACEP Category 1 credit.

Disclaimer

ACEP makes every effort to ensure that contributors to College-sponsored programs are knowledgeable authorities in their fields. Participants are nevertheless advised that the statements and opinions expressed in this article are provided as guidelines and should not be construed as College policy. The material contained herein is not intended to establish policy, procedure, or a standard of care. The views expressed in this article are those of the contributors and not necessarily the opinion or recommendation of ACEP. The College disclaims any liability or responsibility for the consequences of any actions taken in reliance on those statements or opinions.

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