Epistaxis (i.e. nosebleed) is a very common complaint in the emergency department. It can potentially be life threatening, although the vast majority of cases are benign.
As with all emergency presentations, the first step is to assess the patient using an ABCD approach.
Ensure the patient isn’t choking on blood, comment on any coughing and inspect the airway. Place the patient sitting upright and leaning slightly forward.
Note: any backward head tilt will encourage blood to flow into the posterior pharynx and into the stomach which will cause the patient to become nauseated and potentially vomit.
Observe the respiratory rate and check oxygen saturations. Auscultate the lungs, listening for any abnormal breathing sounds/gurgling which may indicate the patient is bleeding into their posterior pharynx and compromising their airway.
Assess heart rate and blood pressure to rule out hypovolaemic shock secondary to significant and prolonged epistaxis.
Assess the patient’s current level of consciousness which may be affected if large volumes of blood have been lost (this would indicate need for immediate senior input).
If you are concerned about any of these ABCDs call for help and treat according.
If the patient is stable then it’s time to move on with history, examination and management. In epistaxis you may choose to initiate the first step of management while you are taking the history and examining.
While you are assessing the ABCDs, have the patient apply pressure to their nose in order to tamponade the bleeding. Make sure they are holding very firmly in the correct location (on the border of the nasal bone). It may be worthwhile to demonstrate the location and pressure to ensure correct technique.
Once you have commenced the tamponade it’s time to take a history.
In a focused epistaxis history you’ll need to find out:
- Onset – how long have they been bleeding
- Precipitating event – what were they doing when it started? – most epistaxis is caused by trauma (e.g. nose picking) so be sure to specifically ask about this as the patient will most likely not volunteer this information.
- Quantity of blood loss – how many cups of blood do they estimate they’ve lost (remember that patients & doctors are notoriously poor estimators, but it’s still worthwhile asking)
- Frequency – # of rebleeding events
- Past Medical Hx – have they had this previously / number of times / how was it controlled previously?
- Medications – anticoagulants / antiplatelets (severe epistaxis in the context of anticoagulation may require reversal, however this should be a senior led decision with haematology input if required)
- Past Surg Hx – facial surgeries (e.g. rhinoplasty) can make it more difficult to control bleeding
- Social Hx – recreational drug use (e.g. cocaine) is important to ask about
At this stage you’ll need to get a look at the nose.
1. Get on the appropriate personal protective equipment (PPE), glasses and gown included.
2. Have the patient blow their nose to clear the blood and then using a pen torch with a nasal speculum view the nasal passage.
3. Comment on active bleeding, lesions and any obvious sources of bleeding. Also note whether the bleeding is bilateral or unilateral.
4. Have the patient gargle water and spit, then visualise the back of the throat and look for blood in the posterior pharynx. Most patients with any epistaxis (anterior or posterior) will have blood in the back of the throat because even those with anterior bleeding swallow blood running down their face.
Warning signs that this may be a posterior bleed:
- No sources of obvious sources anterior bleeding
- Bilateral nare bleeding
- Blood in the posterior pharynx
Posterior bleeds are serious and have a different management from anterior bleeds
Management (anterior bleeds)
If you’ve assessed the patient and you’re convinced the bleed is anterior then you can work through these simple steps until the bleeding stops.
1) Tamponade bleeding (10-15 minutes)
2) Apply topical vasoconstrictor – The type of vasoconstrictor will vary with institutions, one example is lidocaine with epinephrine. Once vasoconstrictor has been applied, continue the tamponade. If this fails and you have identified a local source of bleeding then move onto step 3.
3) Cauterize with silver nitrate – Get a good visual on the lesion and apply silver nitrate (be sure to warn the patient that it might feel uncomfortable. Be aware that this may cause the patient to sneeze, so ensuring you wear appropriate personal protective equipment is important. If this still doesn’t stop the bleeding or there are no localised lesions then move onto step 4.
4) Nasal pack – Apply a nasal pack (these are essentially a nasal catheter/tampon). Insert them posteriorly, in the same direction as you’d insert an NG tube. These need to remain in for at least 24 hours and if the patient is on anticoagulants or has a history of rebleeding you should leave them for 48 hours.
Complications of nasal packs include toxic shock syndrome (exceedingly rare), rebleeding, septal necrosis, packing displacement leading to asphyxiation, ethmoid/nasal bone fractures.
5) Ear, nose and throat specialist input – if bleeding remains uncontrolled after step 4 it’s time get an urgent specialist opinion.
Management (posterior bleeds)
Posterior bleeds can result in life threatening epistaxis. Patients’ are often elderly and report that direct pressure has had no effect. The patient may have experienced haematemesis due to swallowing large amounts of blood. Typical examination findings include the absence of anterior sources, bilateral nare bleeding and blood noted in the posterior pharynx.
1) Identify and call for help – Due to their potentially serious nature, once identified they should brought to the attention of senior staff immediately. Ensure the patient’s vitals are stable as part of an ABCD assessment.
2) IV access + bloods – Insert x2 large bore IV cannulas. Take bloods for group and hold as well as basic bloods including coagulation studies.
3) Insert posterior nasal pack kit or foley catheter – Some hospitals will have devices specifically for posterior epistaxis, however if yours doesn’t, a foley catheter can be used.
- Apply topical anesthesia and consider sedation as the insertion of the device will be uncomfortable
- Insert the lightly lubricated urinary catheter into the nasal cavity until you can visualise it at the posterior pharynx.
- Fill the catheter with 10mL of normal saline or air and then retract it until it lodges against at the choana.
Severe refractory cases of epistaxis will require admission under the care of the ENT team.
Patient education on the relevant causes (e.g. nose picking / cocaine use).
Advise the patient to avoid blowing their nose.
This is a brief overview of epistaxis. For more details I recommend you take a look at any of the resources I’ve referenced.
- Life in the fast lane (http://lifeinthefastlane.com/epistaxis/)
- EM Basic Podcast
- Toronto Notes