CME

Managing epistaxis Linda Diamond, PA-C

ABSTRACT An estimated 60% of the population will have a nosebleed in their lifetime, and 6% will require medical intervention. Uncontrolled nasal bleeding can lead to hypovolemia and airway compromise. Understanding prevention and management of epistaxis is especially important to clinicians who manage patients on anticoagulants, supplemental oxygen therapy, or who have other risk factors for epistaxis. This article reviews stepwise management for epistaxis and newer treatment options in adults. Keywords: epistaxis, nosebleeds, nasal packing, thrombogenic agents, balloon catheter, anticoagulation

Learning objectives Identify risk factors and causes of epistaxis. Describe the stepwise management of epistaxis. List the equipment and medications needed to manage epistaxis.

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pistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx. Nosebleeds are a common condition and most are selflimiting. However, uncontrolled nasal bleeding can lead to hypovolemia and airway compromise. This article reviews the risk factors, prevention, and management of epistaxis, including management for patients on anticoagulants or supplemental oxygen. Newer treatment options offer patients and clinicians a better arsenal to treat epistaxis. CAUSES Epistaxis is a frequent phenomenon. An estimated 60% of the population will have a nosebleed in their lifetime, and 6% require medical intervention.1,2 The incidence of epistaxis is a bimodal distribution, peaking in young children and again in adults ages 45 to 65 years.2 Epistaxis Linda Diamond practices ENT head and neck surgery at Allegheny General Hospital in Pittsburgh, Pa. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000455643.58683.26 Copyright © 2014 American Academy of Physician Assistants

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FIGURE 1. Anatomy of the nasal cavity

can be caused by a variety of factors (Table 1). Anticoagulation, underlying liver disorders, or other blood coagulopathies can contribute to the inability to control epistaxis. Recurrent or unilateral epistaxis along with nasal congestion or nasal obstruction, independent of the degree of bleeding, may indicate nasal neoplasm. www.JAAPA.com

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CME

Key points An estimated 60% of the population will have epistaxis at some time, and 6% will require medical treatment. Newer options for nasal packing and thrombogenic materials are less traumatic for patients and healthcare professionals. Patients on anticoagulant or antiplatelet medications should be instructed in nasal care to reduce the risk of epistaxis. An epistaxis kit of necessary instruments and supplies may help healthcare providers treat patients more efficiently and effectively.

ANATOMY The nasal cavity—two chambers divided by the nasal septum—warms and moistens the air we breathe. The septum is lined by mucous membrane and contains a rich vascular supply generating from branches of the internal and external carotid arteries. More than 90% of cases of epistaxis occur on the nasal septum in the vascular area called the Kiesselbach plexus.1 This area is prone to digital trauma and excessive drying, and is exacerbated by the use of supplemental oxygen via nasal cannula. The Kiesselbach plexus is supplied by both the anterior and posterior ethmoid arteries as well as branches from the sphenopalatine and greater palatine arteries (Figure 1). Epistaxis in this area is defi ned as anterior and is generally self-limiting and easier to control. The lateral wall of the nasal cavity is more complex, with three bony elevations called turbinates or conchae. These conchae are covered with a thick mucous membrane and increase the surface area to moisten inhaled air. Posterior nasal cavity epistaxis occurs in 5% to 10% of nasal bleeding.1 Branches of the internal maxillary artery (sphenopalatine and descending palatine arteries) with a small contribution from the posterior ethmoid artery make up the vascular supply to this area. Posterior epistaxis is often more difficult to visualize and to reach anatomically, therefore, more difficult to control.1,2 HISTORY AND ASSESSMENT Obtaining a timeline of the patient’s nosebleed is important; the duration of the bleeding may indicate whether the patient needs more emergent treatment. Refer the patient to the nearest ED if he or she has had recurrent hard-tocontrol bleeding over several days or a single significant bleed lasting longer than 1 hour. Review the patient’s medical history, looking for chronic medical conditions that may predispose the patient to bleeding, such as hypertension, liver disease, heart disease, or blood disorders. Note and document if the patient is taking anticoagulants or antiplatelet 36

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TABLE 1.

Causes of epistaxis

Traumatic • Nose picking • Facial injury • Foreign body • Nasogastric tube placements • Barotrauma Neoplastic • Benign • Malignant Hematologic • Thrombocytopenia • Hemophilia • Von Willebrand disease • Hereditary hemorrhagic telangiectasia • Hepatic diseases • Anticoagulant or antiplatelet medications Structural • Dryness • Septal perforation • Surgical procedures Drug-induced • Nasal sprays • Substance inhalation Inflammatory • Environmental irritants • Allergic rhinitis • Infections

drugs such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). In the initial evaluation of a patient with epistaxis, focus on airway competency and cardiovascular stability. Patients with severe bleeding may need resuscitation and airway control. Be sure to have adequate lighting when inspecting the nasal cavity in the office setting. A headlight source with a nasal speculum is recommended. Inexpensive headlamps used for camping or recreation can provide a narrow tight beam, allowing better visualization and freeing both of the healthcare provider’s hands. The patient should be sitting upright on examination chair or table to limit head movement. An epistaxis kit containing all the necessary instruments and packing is helpful (Table 2). Bayonet forceps or straight sturdy blunt-ended tweezers about 8 in long are used to insert pledgets or packing. Frasier suction #10 or small disposable suction tips are used to remove clots and blood from the nasal cavity before treatment. Yankauer suction and an emesis basin can be used to capture expectorated clots. TREATING ANTERIOR EPISTAXIS Epistaxis treatment is based on the site and degree of bleeding. Failure to control an anterior bleed may indicate the presence of a posterior bleed. Volume 27 • Number 11 • November 2014

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Managing epistaxis

Compression is recommended initially for a simple anterior septal nosebleed. Have the patient watch a clock or set a timer while holding the fleshy part of the nose for 10 minutes without releasing. If this method fails, the patient will require medical evaluation by a primary care provider, ENT specialist, or in an urgent or emergency care setting. Inspect for bleeding in the Kiesselbach plexus. A locally applied vasoconstrictor can assist visualization and control of bleeding. Oxymetazoline, the active ingredient in several nasal decongestant sprays, is available and easy to use. Suction or have the patient gently blow the nose, then either spray or place a cotton pledget soaked with oxymetazoline in the nares. A pledget can be made using a large cotton ball and unrolling it to about 4 in long. The pledget is best placed using bayonet forceps to insure proper placement along the nasal septum. Let the pledget remain in place with gentle compression for 5 to 10 minutes. After removing the pledget, examine the nares with a headlight and nasal speculum. Chemical cautery may be considered for persistent oozing of an identifiable anterior site. Anesthetize the patient’s nasal cavity with a pledget soaked with 2% lidocaine (with or without epinephrine) for about 10 minutes. Remove the pledget and hold a silver nitrate applicator on the site of bleeding and surrounding area for no longer than 10 seconds. The mucosa will turn whitish gray. Holding the cautery stick on an area for more than 10 seconds poses the risk of septal perforation. Use caution in cauterizing both sides of the septum in the same session, as this may also cause tissue necrosis and possible septal perforation. Nasal packing is available for anterior and posterior bleeding. For a simple anterior nasal bleed that has failed compression and/or cautery, use a nasal tampon, balloon, or a thrombogenic agent. Occasionally, both sides of the nares may require packing either due to bilateral bleeding or to achieve enough compression to control the bleed. Bilateral packing is necessary for patients with septal perforation. Nasal tampons are made of a synthetic open-cell polymer. Although these polyvinyl alcohol sponges are rigid, they are easy to use and effective. Anesthetize the patient’s nare as described above. Coat the nasal tampon with antibiotic ointment to act as a lubricant as well as to prevent infection. Slide the nasal tampon directly along the floor of the nasal cavity until the entire tampon is in the nasal cavity. Then expand the tampon by infusing about 10 mL of saline or sterile water with an angiocatheter or needle onto the anterior nasal tampon to soak the material. Nasal balloon catheters come in different types, including a low-pressure balloon encased in a carboxymethylated cellulose (CMC) mesh. The mesh promotes thrombosis once it contacts blood. These balloon catheters are conJAAPA Journal of the American Academy of Physician Assistants

TABLE 2.

Contents of an epistaxis kit

• Head lamp • Nasal speculum • Bayonet forceps • Frasier suction #10 • Suction setup • Emesis basin • Oxymetazoline • Lidocaine 2% with or without epinephrine • Cotton pledgets or balls/strips • Tongue blades • Eye protection • Nonsterile gloves • Silver nitrate sticks • Antibiotic ointment • Empty 10-mL syringes • Sterile water • Anterior packing (polyvinyl alcohol sponge or lowpressure balloon) • Posterior packing (dual balloon catheter or petroleumimpregnated gauze) • Hemostatic agents of choice

sidered less traumatizing to the nose than traditional nasal tampons. They vary in length to allow compression from the anterior to more posterior bleeding sites. CMC balloons are moistened with sterile water before insertion, and are easy to insert in the nares in the office setting. Remove the hard outer cover, moisten the pack with sterile water, and immediately slide the pack along the floor of the nose until it is completely inserted. (None of the pack should be sticking out of the patient’s nose.) Then inflate with air until the pilot cuff is firm. Tape the cuff to the patient’s cheek. Gauze packing with petroleum-impregnated ribbon gauze can be used to control epistaxis. The packing is placed with a bayonet forcep. Grasp the gauze and place it as far back in the nasal cavity as possible, then grasp the next segment of gauze and tightly layer each segment into the nare. This requires a greater skill in placement and may be deferred to an ENT specialist. Thrombogenic agents are newer options to promote clot formation and stabilize epistaxis. Forms include surgical absorbable gauze, topical thrombin gel, and fibrin glue. The medicated gauze and topical applications conform to irregular and wet mucosal surfaces. Medicated gauze can be placed after cautery in patients at high risk for recurrent bleeding. Studies indicate that thrombogenic agents have a lower rebleeding rate and effectively control epistaxis.3,4 Patients have less nasal pressure and find these interventions more comfortable than traditional nasal packing or balloons. Because this form of treatment is absorbable, it does not have to be removed. This prevents clots from being dislodged or the nasal mucosa from www.JAAPA.com

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CME

being further irritated, as can occur during removal of traditional packing. Thrombogenic agents need to be applied directly to the area of bleeding and compression may still be required initially. When evaluating bleeding, remember that these agents may take several minutes to work. TREATING POSTERIOR EPISTAXIS Because visualization and access to the bleeding site is difficult, posterior epistaxis is challenging to treat. The nares can be packed with petroleum-impregnated gauze or a posterior balloon can be placed. A dual balloon catheter is inserted along the floor of the nose until the retention ring is at the nasal entrance. The posterior bal-

Surgical treatment is reserved for ongoing hemorrhage that fails conservative interventions. loon is inflated with 10 mL of sterile water and the catheter is gently pulled forward until it lodges against the nasopharynx. The anterior balloon is then inflated with up to 30 mL of sterile water to hold the catheter in place. Pad or protect the nasal entrance from any pressure the balloon may create in its placement. Although not licensed for this use, an indwelling urinary catheter works well if a balloon catheter is not available. Insert a 10-to-14 French catheter into the nasal cavity until the indwelling urinary catheter is visible in the oropharynx. Then slowly inflate the balloon with 10 mL of sterile water and gently withdraw the catheter until compression occurs on the posterior nasopharynx. While maintaining pressure on the posterior nasopharynx (pulling the catheter toward yourself), place a small C-clamp or umbilical clamp at the anterior nares to hold the catheter. Ribbon gauze or packing may be placed around the catheter inside the nares for added compression and control of bleeding. Apply a gauze dressing to protect the external nares from the clamp and pressure necrosis. AFTER PACKING TREATMENT After the nasal cavity has been treated or packed, always use a light source and tongue blade to evaluate the oropharynx to check for posterior bleeding. Epistaxis that persists after packing is placed requires immediate referral to an ED. Packing that results in good control should remain in place for 3 to 5 days. Although experts have debated whether to prescribe prophylactic oral antibiotics to prevent toxic shock syndrome and sinusitis while the packing is in place, most ENT surgeons 38

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prefer prophylaxis.5 Simple anterior packing on one side can be treated as an outpatient procedure, with referral to an ENT specialist for follow-up in 3 to 5 days. Patients who require bilateral packing or posterior packing will need hospital admission and monitoring. The potential risk of hypotension and bradycardia caused by a nasovagal reflex is rare. This “nasopulmonary reflex” was thought to occur during posterior nasal packing or instrumentation but studies have demonstrated no change in pulmonary or cardiac function in relation to posterior nasal packing.6 Patients are at possible risk of short-term sleep apnea due to the decreased nasal air entry from the packing.1,4 The risk of displacement of the packing and possible recurrent bleeding warrants ICU admission or a high level of monitoring. A hospitalized patient will benefit from a humidified face tent to provide moisture and comfort; the nasal packing forces patients to breathe through the mouth while sleeping. UNCONTROLLED EPISTAXIS Angiography with embolization was first performed for epistaxis in 1972.2 Since then, it has become a common alternative for uncontrolled epistaxis in medical centers where it is available. Patients usually require anesthesia and must tolerate IV contrast for this procedure. Studying endovascular treatment for intractable epistaxis in 30 patients, Vitek found a success rate of 87% after embolization of the internal maxillary artery and a 97% success rate after embolization of the internal and facial arteries, with a 3% to 4% complication rate.7 Failure of embolization treatment of epistaxis is often related to continued bleeding from the ethmoidal branches of the ophthalmic artery. Embolization of these branches is contraindicated because ophthalmic artery embolization carries a high risk of blindness and stroke. Surgical treatment is reserved for ongoing hemorrhage that fails conservative interventions. Surgery is performed in the OR under general anesthesia; rigid endoscopy is used to identify the site of bleeding. Surgical ligation or cautery of the sphenopalatine artery is attempted initially. Studies of posterior endoscopic cauterization report success rates of 80% to 90%.2 If the site of bleeding is found from the ethmoidal region, a ligation of the ethmoid artery is completed. This may require an external incision through the medial orbital wall just below the eyebrow. Traditional or absorbable nasal packing may be placed in the nasal cavity postprocedure as a precaution. ANTICOAGULATION AND HYPERTENSION Managing epistaxis in patients taking anticoagulants is challenging. Much debate and little consensus exist as to whether anticoagulation should be continued, held, or reversed when patients develop epistaxis.3 Medically Volume 27 • Number 11 • November 2014

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Managing epistaxis

evaluate each patient to determine the risks of stopping anticoagulation. The role of hypertension in the initial onset of epistaxis is controversial.8,9 Studies have demonstrated that patients with epistaxis presenting to the ED have higher BP on admission than controls. These patients also have a higher incidence of previous nosebleeds.9 Patients with epistaxis and uncontrolled BP can have persistent bleeding that is difficult to control, so medical management of hypertension is vital. The hypothesis that elevated BP was secondary to anxiety during epistaxis also was studied. This prospective comparative study looked at administering

Moisture is the key to prevention. Patients with nasal dryness should use saline nasal spray. diazepam to patients with epistaxis, increased BP, and anxiety. The researchers found that diazepam did not reduce anxiety or BP during acute epistaxis and was not recommended.10 Therefore, evidence supports that hypertension itself must be controlled in a patient with acute epistaxis and should be monitored closely. FOLLOW-UP AND PREVENTION All patients with a history of severe or recurrent epistaxis should have an ENT evaluation. Provide patients with written instructions for nasal care after epistaxis: • Patients should not blow their noses for 7 to 10 days after the nosebleed. Patients should use saline nasal spray several times a day and sniff gently instead of blowing the nose. • Patients should apply petroleum or antibiotic ointment in the nares twice a day. • Patients should avoid bending and lifting heavy objects. • Advise patients to open their mouths when sneezing. • Patients should use home humidifiers and bedside vaporizers. • Tell patients to keep fingernails trimmed and avoid nose picking. • For patients on supplemental oxygen, a humidified face tent or mask is recommended. Limit the use of a nasal cannula to during meals. Patients also should trim the prongs of the tubing that enter the nose to prevent excessive dryness on the septum. Moisture is the key to prevention. All patients on anticoagulation or antiplatelet medications (including NSAIDs) should use nasal care. Patients with nasal dryness or a JAAPA Journal of the American Academy of Physician Assistants

history of nosebleeds should add nasal care to their daily regime. Most nosebleeds are cyclic. A patient may have an idiopathic nosebleed that stops as a clot is formed over the bleeding site. If the patient’s nose becomes dry or is blown and the clot becomes dislodged too soon, the nose bleeds again. Until the mucosa underlying the clot is allowed to heal, a patient may continue to have serial bleeds. Moisture and prohibiting nose-blowing stops this cycle and lets the nasal lining heal. Teaching patients how to correctly try to control a nosebleed and perform proper nasal care after a nosebleed may prevent an unnecessary trip to a clinic or ED. CONCLUSION Epistaxis is a common medical event. Newer treatment options are available and friendlier for healthcare providers and patients. Creating an epistaxis kit with all necessary instruments and supplies can help clinicians treat patients in an organized, stepwise fashion with confidence. Provide patients with written instructions about treating nosebleeds and reducing recurrences. Encourage patients on anticoagulation or oxygen to perform nasal care on a daily basis to prevent epistaxis. JAAPA Earn Category I CME Credit by reading both CME articles in this issue, reviewing the post-test, then taking the online test at http://cme.aapa. org. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of November 2014.

REFERENCES 1. Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg. 2006;64(3):511-518. 2. Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. 2005;81(955):309-314. 3. Choudhury N, Sharp HR, Mir N, Salama NY. Epistaxis and oral anticoagulant therapy. Rhinology. 2004;42(2):92-97. 4. Kilty SJ, Al-Hajry M, Al-Mutairi D, et al. Prospective clinical trial of gelatin-thrombin matrix as first line treatment of posterior epistaxis. Laryngoscope. 2014;124(1):38-42. 5. Mathiasen RA, Cruz RM. Prospective, randomized, controlled clinical trial of a novel matrix hemostatic sealant in patients with acute anterior epistaxis. Laryngoscope. 2005;115(5):899-902. 6. Jacobs JR, Levine LA, Davis H, et al. Posterior packs and the nasopulmonary reflex. Laryngoscope. 1981;91(2):279-284. 7. Vitek J. Idiopathic intractable epistaxis: endovascular therapy. Radiology. 1991;181(1):113-116. 8. Herkner H, Havel C, Müllner M, et al. Active epistaxis at ED presentation is associated with arterial hypertension. Am J Emerg Med. 2002;20(2):92-95. 9. Herkner H, Laggner AN, Müllner M, et al. Hypertension in patients presenting with epistaxis. Ann Emerg Med. 2000;35(2): 126-130. 10. Thong JF, Lo S, Houghton R, Moore-Gillon V. A prospective comparative study to examine the effects of oral diazepam on blood pressure and anxiety levels in patients with acute epistaxis. J Laryngol Otol. 2007;121(2):124-129. www.JAAPA.com

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Managing epistaxis.

An estimated 60% of the population will have a nosebleed in their lifetime, and 6% will require medical intervention. Uncontrolled nasal bleeding can ...
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