Patients with epistaxis (“nosebleeds”) will commonly present to the Emergency Department, and junior doctors may also encounter this problem on the wards.

Case

A 72-year-old lady presents to the Emergency Department with a nosebleed which has lasted several hours (most of the afternoon). She has a background of a blocked nose and sinus pain for several weeks. When you first review her, her shirt appears covered in a large amount of blood, and she reports feeling light-headed.

1. What is your initial approach to this patient?

Epistaxis is a serious problem – not one to be sneezed at!
Start with your usual ABC assessment
- Assess the airway
- Measure vital signs, consider postural BP
- Given the history of light-headedness, establish IV access and perform bloods, particularly checking haemoglobin

2. Outline your assessment approach by the bedside

History
- Try to determine whether it’s an anterior or posterior bleed – is blood coming from the front of the nose, or going down the back of the throat? Is the blood coming from a particular nostril?
- What has the patient done to try and stop the bleeding?
- The correct technique to attempt to stop a nosebleed manually is to firmly squeeze the soft part of the nose (not the bony bridge), for at least 10 minutes.
- If the patient has done this and the bleeding stopped, this suggests an anterior bleed.
- Has she had nosebleeds before? Nasal surgery? Hypertension?
- On any blood thinners (aspirin, NOACs, warfarin)? Always ask about fish oil.
- Has she had any interventions before to try and stop nosebleeds, or any trauma to the nose?
Examination
- Preparation: protect yourself with eye protection, a mask, and gloves. Position the patient with good lighting – most EDs have a head-light you can use.
- Spray co-phenylcaine (lidocaine and phenylephrine) twice into each nostril before looking – note, this cannot be used in pregnancy.
- Drixine is also helpful, and can be applied with a cotton bud by the patient whilst squeezing the nose.
- Have a tongue depressor, nasal speculum, and suction ready to use.
- Sit the patient upright, at an appropriate height that you can see up the nose.
- Examine the throat – look for clots at the back of the throat.
- Examine the nose for a source of bleeding with the nasal speculum.

3. What are some of the underlying causes of epistaxis?

Hypertension
Anticoagulants
Post-surgical: sinus or turbinate surgeries
Previous trauma (could cause anatomical predisposition to bleed)
Rarer conditions such as Wegener’s Granulomatosis, telangiectasia

4. What are some anatomical features to be aware of?

Anterior and posterior bleeds
- 90% of the nosebleeds you see will be anterior, and most come from Little’s Area.
- Little’s Area – in the anterior part of the nose, where three blood vessels converge. Rich vascular supply in this area. Blood supply here is from internal carotid and external carotid arteries, but mostly from the sphenopalatine artery. This means sucking on ice can help stop bleeding.
- 10% are from the posterior part, with some contribution from the sphenopalatine artery.

5. Investigations for epistaxis

Full blood count: check haemoglobin
Coagulation studies (especially if on warfarin)
Group and Hold (particularly in the elderly, post-surgical, anticoagulated, significant bleed, abnormal vitals)
Some patients may not require bloods, if they are young and healthy, with a convincing history and examination for an anterior bleed which has stopped.

6. Management of epistaxis

Anterior bleeds
- Nasal decongestant – apply to a cotton ball
- Co-phenylcaine spray
- Silver nitrate stick, with suction to remove clots. This stings, so use co-phenylcaine first. Caution: less is more. Wait a few seconds between applications, otherwise you’ll end up with a large scab. Do not apply silver nitrate to the same point on the opposite side of the septum – risk of perforation.
- If you see a small clot, with good visualisation, consider suctioning the clot.
- If silver nitrate doesn’t work, put a cotton bud with drixine against the septum and leave it there for 10 minutes. Ask the patient to suck ice. Reassure the patient.
- Adrenaline-soaked gauze is sometimes used.
- Surgicel may be used.
- Topical tranexamic acid is sometimes used.
Posterior bleeds
- Rapid Rhino: shouldn’t be required in an anterior bleed.
When should a junior doctor escalate to ENT or Senior ED doctor?
- Post-surgical patients: speak with ENT before putting any instruments in the nose.
- Continual bleeding despite appropriate first aid and management as described above, with clots in the back of the throat.
- Haemodynamic instability.

7. The epistaxis continues. What should you do next?

Establish another large IV cannula, and resuscitate.
Treat reversible causes (e.g. supratherapeutic INR).
Rapid Rhino can be used at this point – particularly if there is limited ENT cover at your hospital.
- To activate, you need to put in water (this will act as a lubricant, no additional lubricant required).
- The Rapid Rhino is painful for the patient – re-apply the topical anaesthetic.
- Direct them straight along the floor of the nasal cavity.
- Inflate gently with a few mls of air only initially – can inflate further if no success.
- Don’t put two Rapid Rhinos in one nostril. Can put one in each nostril, however you’ll need to deflate the first one before putting in the second.
ENT team will consider FLOSEAL to attempt haemostasis, and nasendoscopy to look for a source of bleeding.

8. What are the indications for admission, and are there red flags we should know about?

Unstable patient with multiple comorbidities.
Some hospitals will admit all patients who need a Rapid Rhino.
If the Rapid Rhino is not working well, the patient may require surgical management.
All posterior bleeds.

9. Are antibiotics required when using a Rapid Rhino?

There is no evidence to support routine antibiotic use, however some clinicians may use antibiotics for Staph cover (to avoid a toxic shock syndrome picture, similar to that associated with tampons).
Cephazolin or Keflex is usually fine for this purpose.

10. What follow up is required for patients being discharged from ED after the epistaxis has resolved?

ENT Clinic within 1 week for most patients.
Send home on Drixine – 3 sprays, 3 times a day, for 3 days.
Lubricant (e.g. Chlorsig) after the Drixine.
Counsel patient that after the scab falls off there may be a small bleed.
No nose-blowing, no nose-picking, no intensive exercise for a few days.
No restrictions to diet (i.e. hot food and drink is ok).

Take home messages

First aid is crucial: pressure to the soft part of the nose, use drixine.
Rapid Rhino is uncomfortable and can cause mucosal damage – avoid wherever possible.
Be patient.