Describe epistaxis with its causes and management.

Sites and Causes

• Epistaxis is bleeding from the nose.
• It is a symptom, not a diagnosis, and is the commonest ENT emergency.
• It is classified by site into anterior and posterior, a distinction that governs both severity and management.

Management

• 1.
• Resuscitate first if the bleeding is heavy — assess airway, breathing and circulation; obtain intravenous access, take blood for full blood count, group and save or cross-match, and clotting; and give fluids.
• A patient can exsanguinate from the nose → 2.
• Position and first aid — sit the patient upright and leaning forward, so blood is not swallowed (which causes vomiting) or aspirated; pinch the soft part of the nose, not the bony bridge, for 10 to 15 minutes continuously; and ask the patient to spit blood out.
• Apply ice to the neck or forehead → 3.
• Remove clot by blowing or suction and inspect with good light and a speculum.
• Nothing can be treated until the nose has been cleared → 4.
• Topical vasoconstrictor and anaesthetic on a pledget — lignocaine with adrenaline or phenylephrine — left for several minutes, which frequently stops the bleeding by itself and always makes what follows tolerable → 5.
• Identify the bleeding point and cauterise — silver nitrate chemically or electrocautery.
• Cauterise around the vessel first, then the point itself, and never cauterise both sides of the septum at the same sitting, which risks perforation → 6.
• If bleeding continues, pack the nose — a nasal tampon (Merocel), inflatable balloon pack, or ribbon gauze impregnated with bismuth iodoform paraffin paste (BIPP).
• Pack along the floor of the nose, horizontally, not upward → 7.
• Posterior bleeding — a postnasal pack, a FOLEY catheter inflated in the nasopharynx and drawn forward, or a double-balloon device.
• These patients must be admitted → 8.
• Surgical or radiological intervention where packing fails — endoscopic sphenopalatine artery ligation or clipping, which is now the procedure of choice; anterior ethmoidal artery ligation where bleeding is high in the nose; and angiographic embolisation
• Why endoscopic sphenopalatine ligation has replaced the older operations — it is close to the bleeding point, so collateral flow cannot maintain the haemorrhage. Maxillary artery ligation in the antrum and external carotid ligation are more proximal, have a higher failure rate, and external carotid ligation cannot control bleeding from the ethmoidal arteries.
• Points about packing — give antibiotic cover for packs left beyond 24 to 48 hours, because of sinusitis and the risk of toxic shock syndrome; remove the pack at 24 to 48 hours; and be aware that packing may cause hypoxia through the nasopulmonary reflex, particularly in the elderly and in those with respiratory disease, who need oxygen saturation monitoring
• Treat the cause, not just the bleed — control hypertension; review and where possible correct anticoagulation, in discussion with the physician; correct coagulopathy; and treat rhinitis or crusting
• DO not reflexly stop anticoagulation in a patient with a mechanical valve or recent thrombosis; the decision is a balance and should be made jointly
• Prevention and advice on discharge — NO nose-picking, NO forceful blowing, NO hot drinks or hot baths for a few days; petroleum jelly or an antiseptic cream to Little’s area.