Epistaxis – OSCE Case

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Introduction

A 76-year-old man is brought to the emergency department via ambulance with epistaxis. Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations:

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History

Presenting complaint

“My nose started bleeding earlier on and I just couldn’t get it to stop.”

History of presenting complaint

When did it start?

“About 2 hours ago”

How did it start?

“It just started bleeding really heavily out of nowhere while I was having a cup of tea”

Which nostril is it coming from?

“Hard to say, I think more the left side”

What did you do once it started?

“Put a tissue up my nose and called an ambulance”

Is it running down the back of your throat?

“Only if I lean back”

Is it still bleeding?

“I think so”

Has there been any recent trauma?

“No”

Any bleeding from anywhere else?

“Don’t think so”

Do you have any chest pain/shortness of breath/lightheadedness?

“I’m feeling a bit woozy”

Have you had anything similar previously?

“I used to have nosebleeds as a child but none for years”

Have you been otherwise well recently?

“I had a chest infection last week so I’ve been on antibiotics but that’s gotten better”

Other parts of the history

Past medical and surgical history

  • Do you have any other medical problems?

Specifically, ask:

  • Have you ever had any problems with bleeding or clotting?
  • Have you had nosebleeds before?
  • Have you ever had to come to the hospital for a nosebleed?

“I had a metallic heart valve put in years ago and I’ve got high blood pressure. I’ve had the odd nosebleed in the past but nothing like this before.”

Medication history/allergies

  • Do you take any regular medications?
  • Are you allergic to anything?

Specifically, ask:

  • Are you taking any blood thinners?

“I take warfarin for my heart valve and some blood pressure medications. I’m allergic to penicillin.”

Family history

  • Are there any medical problems that run in the family?

Specifically, ask:

  • Is there any history of problems with bleeding or clotting in the family?

“Nothing that I know of”

Social history

  • Do you live with anyone?
  • Do you smoke?
  • Have you ever smoked?
  • Do you drink alcohol? If yes, how many drinks would you say you have in a week?
  • Do you use any recreational drugs?

“I live alone, my wife died a couple of years ago. I smoked for about 30 years but gave up after my heart valve surgery. I don’t drink or take drugs”


Clinical examination

This patient has had a heavy, persistent nosebleed and is anticoagulated so there is a possibility of significant blood loss and haemodynamic compromise. A rapid ABCDE approach should be taken, including a set of observations.

Observations:

  • Respiratory rate 18/min
  • SpO2 98% on air
  • Pulse 110/min
  • Blood pressure 96/43
  • Temperature 36.1oC

ABCDE assessment

  • Airway:Β no concerns currently, talking in sentences
  • Breathing:Β chest clear with bilateral air entry
  • Circulation:Β tachycardic, regular pulse, cool peripheries, capillary refill time 4s peripherally and 2s centrally. A metallic click is heard over the mitral region
  • Disability:Β GCS 15, alert and orientated. Moving all 4 limbs
  • Exposure: peg applied to the nose. No active bleeding with this in situ, but large volumes of dried blood on the patient’s clothes. No other obvious sources or sites of bleeding. The abdomen is soft and non-tender.

The external nose should be examined for any obvious deformity or signs of trauma. There is a peg in situ currently, which has temporarily stopped the bleeding. However, this will need to be removed to assess whether the bleeding is ongoing and where it is coming from.

Nasal thudichums should be used with a light source to examine inside the anterior aspect of both nostrils for potential bleeding sites. In addition, the oropharynx should be examined to look for active blood trickling down the back of the throat.

Examination findings

  • There are no obvious signs of external trauma to the nose.
  • When the peg is taken off, a trickle of blood begins to run from the left nostril.
  • On attempted examination, there are a few flecks of dried blood in the right nostril, and the left is obscured by active bleeding and a large clot.
  • There are no obvious polyps, masses, or foreign bodies, although it is difficult to fully examine for these.
  • There is no blood running down the posterior aspect of the oropharynx.

Investigations

Blood tests are most appropriate to arrange initially. This patient has potentially lost a large volume of blood and is taking warfarin, so he needs an urgent set of blood tests, including an INR and a group & save.

A venous blood gas (VBG) will provide a rapid haemoglobin and lactate level, which may aid initial management. This should be done in conjunction with achieving IV access with wide-bore cannulae and commencing resuscitation.

Investigations such as XR and CT facial bones have more utility in the setting of trauma, although imaging is not necessarily required if the only query is a nasal fracture with a small, self-resolving nosebleed. They may be appropriate if there is concern about wider facial trauma or significant deformity.

Fibreoptic nasendoscopy may be used to more closely examine the nasopharynx for sites of bleeding and abnormalities such as polyps or masses. This does not need to be done acutely if there is an obvious bleeding point anteriorly and should be performed once the patient is stabilised.

A chest X-ray may be required given the patient’s recent chest infection and the possibility of having aspirated blood, but he is saturating normally on room air, and this is not required as a first-line investigation.


Diagnosis

The significant majority of nosebleeds are anterior in origin. In particular, Little’s area on the nasal septum has a collection of blood vessels known as Kiesselbach’s plexus. This region is particularly susceptible to drying out, mucosal thinning, and trauma, making it liable to bleeding.

Blood vessels contributing to the plexus originate from the internal and external carotid arteries, including the sphenopalatine artery, greater palatine artery, superior labial artery, and posterior septal artery. The anterior and posterior ethmoidal arteries are also often included in this.

A small minority of nosebleeds come from the posterior nose. This may be suspected if blood predominantly trickles down the throat from the onset or bleeds despite anterior nasal packing.

INR results

The patient’s INR result comes back as 6.7. He states that he has recently been taking his warfarin as usual, and it is normally around 3.0-3.5.

The patient has had a recent chest infection for which he has received antibiotics. He is allergic to penicillin, so an alternative antibiotic, such as a macrolide (e.g. clarithromycin), may have resulted in a raised INR via cytochrome P450 inhibition.


Management

Initial first aid management

Firm, sustained pressure should be applied to the soft part of the nose for at least 10 minutes. Encourage the patient to lean forward to prevent blood from running down the throat. If possible, apply an ice pack to the bridge of the nose.

Failure of initial management

Examine the anterior nose for an obvious bleeding point. If there is active bleeding or large clots, this can be difficult – options to help clear the nasal cavity and improve visualisation include suction, removing clots with forceps, and inserting local anaesthetic/adrenaline soaked cotton swabs into the nasal cavity to encourage vasoconstriction.

Nasal cautery

Nasal cautery – either chemical or electrical – can be applied to prominent vessels or bleeding points. This will vary depending on local practice, but silver nitrate cautery sticks are commonly used.

Nasal packing

If there is ongoing bleeding despite cautery or no obvious cautery target, the next step in management is anterior nasal packing.

Multiple packs can be used, but one commonly utilised device is the Rapid Rhinoβ„’. This is a nasal tampon with an inner balloon inflated with air to tamponade any bleeding point. The affected side should be packed; packs can be inserted bilaterally if necessary.

Posterior nasal packing is performed for bleeds originating posteriorly. This is more difficult than anterior packing. The principle involves inserting a Foley catheter through the nose towards the oropharynx and then inflating the balloon once it is appropriately sited.

Surgery is indicated in life-threatening situations where bleeding cannot be stopped with nasal packing, where there is a significant risk of re-bleeding, or where there is suspicion of a sinister underlying cause and examination under anaesthesia is required.

Options include ligation of the sphenopalatine, internal maxillary, or anterior ethmoid arteries.

Angiographic (i.e. endovascular) embolisation of the sphenopalatine artery is also possible but comes with a risk of stroke.

The patient’s INR is high, putting him at risk of further significant bleeding. However, due to his metallic heart valve, he is also at high risk of clotting if his INR is over-corrected and becomes subtherapeutic. Local guidelines on the management of anticoagulation and reversal of warfarin will be available to help with this. Essentially, if there is a life-threatening, uncontrollable haemorrhage, then consideration should be given to reversal, and the haematology team may be able to advise with this.

In practice, however, most nosebleeds can be stopped by nasal packing, and aggressive reversal is not required. Once the patient has a pack in situ and is not bleeding anymore, holding their dose of warfarin for the day and rechecking their INR the day after may be reasonable.


Outcome

The patient has an anterior nasal pack inserted into his left nostril, and the bleeding stops.

His haemoglobin (Hb) level comes back as 69 g/L (normal range 120-180g/L) with a platelet count of 356 x10^9/L (normal range 150-450×10^9/L). He has had 1L of 0.9% NaCl intravenously over 1 hour, and his blood pressure is currently 113/56mmHg with a pulse rate of 97/min.

This patient has a low Hb in the context of acute blood loss, and this should be managed with transfusion of packed red cells.

The management of major haemorrhage has shifted over recent years, with resuscitation with blood products now preferred over crystalloid or colloid fluid. Whilst the patient is not currently in life-threatening shock, he was tachycardic and hypotensive on initial examination and should be managed appropriately.

The patient may need more than 1 unit, but these should be given individually rather than simultaneously. Target Hb varies, but a level of over 80 g/L in someone with ischaemic heart diseaseΒ or over 70 g/L in those without is generally accepted.


Editor

Dr Jess Speller


References

  1. Kucik, C. J., & Clenney, T. (2005). Management of epistaxis.Β American Family Physician,Β 71(2), 305-311.
  2. MacArthur, F. J., & McGarry, G. W. (2017). The arterial supply of the nasal cavity.Β European Archives of Oto-Rhino-Laryngology,Β 274, 809-815.
  3. National Institute for Health and Care Excellence (NICE). NICE Pathways (Trauma): Major haemorrhaging in hospital – Circulatory access and fluid replacement in hospital. Updated May 2021. [LINK]
  4. National Institute for Health and Care Excellence (NICE). NG24 Blood Transfusion. Published Nov 2015. Available from [LINK]

 

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