• 60% of adults experience epistaxis, and 10% seek medical attention.
• 90% anterior, 40% of which are treated conservatively.
• Posterior epistaxis is usually more severe and may require:
  • Admission.
  • Posterior nasal packing with risk of:
    • Nasal trauma or pressure necrosis.
    • Hypoxia, dysrhythmias.
    • Infection.
  • Embolization or arterial ligation.

See “Dundee protocol” for general approach to epistaxis.

Anterior Epistaxis:

1. Topical vasoconstrictor and analgesic:

• Options:
  • 0.05% oxymetazoline and lidocaine 4% or 2% spray or drops.
    • 65% of patients with epistaxis controlled with oxymetazoline alone.
    • Can also apply oxymetazoline to packing after insertion for additional vasoconstriction with expansion.
  • LET solution (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%).
  • 4% cocaine hydrochloride (both anesthetic and vasoconstrictive).
• Apply with gauze or cotton balls in nares for 10 – 15 mins.

2. Apply pressure:

• Patient to apply pressure to nose ala onto septum for 10 – 15 mins OR use tongue blades to apply pressure.
• Attempt twice before proceeding to chemical cauterization or packing.

3. Chemical cautery (silver nitrate):

• Indications:
  • If topical vasoconstrictors and pressure don’t control bleeding.
  • If source has been localized, bleeding has stopped or is mild (works best on relatively bloodless surface as coagulates blood which limits contact with bleeding vessel).
• Clinical pitfalls:
  • Inadequate analgesia.
  • Using on both sides of the nasal septum (risk of ulceration/perforation).
  • Not waiting 4-6 weeks to try again (risk of ulceration/perforation).
• Start on surrounding area and then on source itself. Roll over area 5-10 seconds.

4. Sealants, nasal packing and/or topical tranexamic acid (TXA):

• If conservative measures (steps 1-3) ineffective: Aliem.com

Posterior Epistaxis:

• Consult ENT.
• Posterior packing:
  • Temporizing measure due to higher complication rates.
  • Options:
    • Foam packing (10 cm length).
    • Foley catheter (12 or 14F):
      • Some cut tip beyond balloon (may stimulate gag reflex).
      • Lubricate distal third of catheter with lidocaine gel.
      • Advance Foley tip along nasal floor until end is seen in posterior oropharynx.
      • Inflate with air (< 10 cc to prevent pressure necrosis), then retract against posterior nasal choana.
      • Secure at nasal ala, with padding to prevent pressure injury.
    • Dual balloon epistaxis catheter (e.g. Epistat, Storz T-3100):
      • May cause significant pressure and discomfort.
      • Not always successful.
    • Bilateral anterior nasal packing can help tamponade the septum.

Other Treatments: 

• Warm water irrigation for refractory epistaxis:
• If patient anticoagulated:
  • Resorbable packing (e.g. Surgicel) preferred, to avoid rebleeding during removal.
  • TXA may be beneficial as alternative or adjunct to packing.
  • Comprehensive risk assessment if considering holding medications (see figure 1).
  • Consider reversal if supratherapeutic coagulation studies and moderate to severe uncontrolled bleeding. Consult hematology if uncertain.

Clinical Controversies:

• Hypertension and epistaxis.
• The relationship between hypertension and epistaxis is uncertain.
  • There may be an increased risk of epistaxis secondary to the vasculopathic effects of hypertension, or hypertension may not increase the risk of epistaxis but simply prolong it.
  • Do not treat hypertension, focus on hemorrhage control, analgesia, mild sedation as needed.
• Benefit of prophylactic antibiotics:
  • Toxic Shock Syndrome is a very rare complication of nasal packing.
  • Available evidence does not support routine use of topical or oral antibiotics, but may be considered if:
    • Increased risk of infection (diabetic, immunocompromised, elderly, prosthetic valve).
    • Posterior packing (some reports of severe infections).
  • Options: amoxicillin-clavulanate, 1^st generation cephalosporin, or clarithromycin if penicillin allergy, for 5 days after unpacking.

• General patient instructions:
  • Continue vs. hold antiplatelets or anticoagulants (consider risk benefit).
  • Instructions on how to control bleeding if re-hemorrhage occurs.
  • Analgesics for comfort.
• For resolved anterior epistaxis or chemical cautery:
  • Observe for 1 hour after control. Encourage ambulation prior to discharge.
  • Antibiotic ointment and/or vaseline to coat mucosa TID for 7-10 days.
  • Consider intranasal vasoconstrictors such as oxymetazoline for rebleeding.
• If anterior nasal packing:
  • Follow up in 24-72 hours for removal of packing.
  • ENT follow up if criteria met (see below).
• If biodegradable hemosealant:
  • Nasal saline spray for mucosal healing and biodegrading of product.

• Airway compromise.
• Hemodynamic instability.
• Complications associated with blood loss.
• Recommended for posterior packing (for cardiac monitoring).

• Posterior packing.
• Bilateral anterior packing.
• Uncontrolled anterior epistaxis.
• Recurrent unilateral epistaxis warrants investigation for nasopharyngeal neoplasm.

Useful links:

• BC Emergency Physician’s Network, PECS – Epistaxis Diagnosis in Adults
• ACEP now – Treatment of epistaxis
• ACEP – Approach flow chart (“Dundee” protocol)
• UptoDate – Management and treatment of epistaxis.
• Life In The Fast Lane: Epistaxis
• Epistaxis management in the Emergency Department (ALiEM)

Patient resources:

• UpToDate: The Basics
• UpToDate: Beyond The Basics

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3. American College of Emergency Physicians. Treatment of epistaxis [Internet]. ACEP Now. 2009 [cited 2019 Dec 18].

   
   

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8. Zahed R, Moharamzadeh P, AlizadehArasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med [Internet]. 2013 Sep [cited 2019 Dec 4];31(9):1389–92.

   
   

9. Approach to the adult with epistaxis – UpToDate [Internet]. Uptodate. 2019 [cited 2019 Dec 18].

   
   

10. Movin’ Meat: Drip Drip Drip [Internet]. 2010 [cited 2019 Dec 17].

    
    

11. Bequignon E, Vérillaud B, Robard L, Michel J, Prulière Escabasse V, Crampette L, et al. Guidelines of the French Society of Otorhinolaryngology (SFORL). First-line treatment of epistaxis in adults. Eur Ann Otorhinolaryngol Head Neck Dis [Internet]. 2017 May 1 [cited 2019 Dec 19];134(3):185–9.

    
    

12. Spielmann, P. M., Barnes, M. L., & White, P. S. (2012). Controversies in the specialist management of adult epistaxis: an evidence‐based review. Clinical Otolaryngology, 37(5), 382-389.

    
    

13. Musgrave, K. M., & Powell, J. (2016). A systematic review of anti-thrombotic therapy in epistaxis. Rhinology, 54(4), 292-391.

    
    

14. Biggs, T. C., Baruah, P., Mainwaring, J., Harries, P. G., & Salib, R. J. (2013). Treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients. The Journal of Laryngology & Otology, 127(5), 483-488.

    
    

15. Tran, Q. K., Rehan, M. A., Matta, A., & Pourmand, A. (2019). Prophylactic antibiotics for anterior nasal packing in emergency department: A systematic review and meta-analysis of clinically-significant infections. The American Journal of Emergency Medicine.