INDEX

    Epistaxis – Treatment

    Cardinal Presentations / Presenting Problems, Ears, Eyes, Nose, and Throat, Hematological / Oncological

    Last Updated Aug 05, 2020
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    Context

    • 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.

    Recommended Treatment

    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.
    1. 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.
    1. 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.
    1. 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.

    Biggs et al. 2013 (ref. 14)

    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, 1st generation cephalosporin, or clarithromycin if penicillin allergy, for 5 days after unpacking.

    Criteria For Safe Discharge Home

    • 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.

    Criteria For Hospital Admission

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

    Criteria for ENT Consult

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

    Quality Of Evidence?

    Justification

    • No benefit of prophylactic antibiotics to prevent TTS.
    • Benefit of TXA as alternative to anterior packing.
    Moderate
    • Use of FloSeal as alternative to anterior packing.
    Low-Moderate

    Additional Resources

    Related Information

    Reference List

    1. Villwock JA, Jones K. Recent Trends in Epistaxis Management in the United States. JAMA Otolaryngol Neck Surg [Internet]. 2013 Dec 1 [cited 2019 Dec 19];139(12):1279.


    2. Schlosser RJ. Epistaxis. N Engl J Med [Internet]. 2009 Feb 19 [cited 2019 Dec 17];360(8):784–9.


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


    4. Barnes ML, Spielmann PM, White PS. Epistaxis: A Contemporary Evidence Based Approach. Otolaryngol Clin North Am [Internet]. 2012 Oct [cited 2019 Dec 18];45(5):1005–17.


    5. Gallegos M. Epistaxis Management in the Emergency Department: A Helpful Mnemonic [Internet]. ALiEM: Academic Life in Emergency Medicine. 2017 [cited 2019 Dec 17].


    6. McGinnis HD. Chapter 244: Nose and Sinuses. In:  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e [Internet]. New York, NY; [cited 2019 Dec 17].


    7. Kamhieh Y, Fox H. Tranexamic acid in epistaxis: a systematic review. Clin Otolaryngol [Internet]. 2016 Dec [cited 2019 Dec 17];41(6):771–6.


    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 Otolaryngology37(5), 382-389.


    13. Musgrave, K. M., & Powell, J. (2016). A systematic review of anti-thrombotic therapy in epistaxis. Rhinology54(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 & Otology127(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.


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