Managing Nosebleeds

8/6/2019 Managing Nosebleeds

1/7

Managing Nosebleeds

Junior doctors are likely to see epistaxis in the acute setting, write SamuelCartwright and colleagues

Epistaxes (nosebleeds) are a fairly common presentation in the emergencydepartment, and a working knowledge of the principles of management isimportant for junior doctors. Most cases resolve spontaneously, but patients whopresent at emergency departments need reassurance and prompt structuredcare. We also consider more specialist care.

Most epistaxis is idiopathic, but there are recognised causes (box). In nine casesout of ten epistaxes occur in the Kiesselbachs plexus, at the anterior portion ofthe septum known as Littles area (fig 1). Littles area is an anastomotic arterialplexus that involves all five arteries that supply the septumthe anteriorethmoidal and posterior ethmoidal arteries of the internal carotid artery and the

greater palantine, sphenopalatine, and superior labial arteries of the externalcarotid artery.

Fig 1Vascular anatomy of nasal septal blood supply

Main causes of epistaxisw1

Local

Idiopathic Infection Traumasuch as nose picking, facial injury Neoplasia Foreign body

General

Drugssuch as anticoagulants Blood diseasessuch as leukaemia

1
http://archive.student.bmj.com/issues/08/05/education/212.php#fig1http://archive.student.bmj.com/issues/08/05/education/212.php#fig1


2/7

Hereditary haemorrhagic telangiectasia Hypertension may exacerbate bleeding

Scenario 1A 4 year old boy presents to his general practitioner with hisanxious mother after he had a nosebleed that morning. Trauma from nose

picking is a common cause of bleeding in this age group, but in many children noobvious cause is found. A detailed history may show a tendency for prolongedbleeding and may raise suspicion of a clotting disorder. In any scenario it isworth asking specifically which nostril began bleeding first. Bilateral bleeding isuncommon.

Initial first aid

Basic first aid is Trotters methodmanual compression of the lower nostrils;sitting upright to reduce blood pressure; and leaning forward to stop swallowing(fig 2). Apply pressure continuously for up to 10 minutes. In this time assess thepatient for signs of shock and resuscitate appropriately. Applying pressure higher

up, to the bony bridge of the nose, is ineffective because no pressure is appliedto the septum.

Fig 2Trotters method, compressing the lower nostrils and applying pressure tothe septum

Management

If simple pressure works it is likely that the bleeding point is on the nasal septumor in the anterior nasal cavity. Look for the offending vessel, and cauterise it toprevent further bleeding.w2 You should wear gloves, a gown, and eye protection.

The patient should clear their nose by blowing it, with caution.

Examine the nose using a headlight if available, which leaves both hands free touse instruments and apply suction. A Thudicums speculum is the instrument ofchoice (fig 3). Ask an ear, nose, and throat surgeon how to hold one becausethere is a knack. Other nasal speculums existfor example, Vienna, Hartmann-Halle, and Cottle speculums. A good view of the septum is often obtained by

raising the nasal tip with the thumb (fig 4).

2
http://archive.student.bmj.com/issues/08/05/education/212.php#fig2http://archive.student.bmj.com/issues/08/05/education/212.php#fig3http://archive.student.bmj.com/issues/08/05/education/212.php#fig4http://archive.student.bmj.com/issues/08/05/education/212.php#fig2http://archive.student.bmj.com/issues/08/05/education/212.php#fig3http://archive.student.bmj.com/issues/08/05/education/212.php#fig4


3/7

Fig 3Thudicums speculum in situ

Fig 4Raising the nasal tip with the thumb

In scenario 1, indicators of shock are a good starting point for managing thepatient, but the extent to which they affect treatment varies. Bleeding in childrenis usually less severe but may be persistent and troublesome. Treatment with

petroleum jelly, chlorhexidine and neomycin cream, or silver cautery may beused.

Remove stubborn clots by suction. A topical anaesthetic combined with avasoconstrictor makes inspection of the nose easier. Examples are lidocaine withadrenaline; co-phenylcaine; or cocaine solution, which is used less often becauseof dysrhythmogenic properties. Apply these to the nose as spray or on a cottonwool pledget placed in the nose with nasal dressing forceps.w3 Leave to work for10 minutes or so to encourage as much vasoconstriction as possible.

Scenario 2An elderly man presents with recurrent nose bleeds in the last fourweeks. The bleeds are not torrential, but Trotters method is not sufficient toresolve the problem.

3


4/7

In older patients the nasal vessels may not constrict as readily because ofassociated vascular disease. In many cases the offending vessel will be seenclearly on Littles area. If Littles area is not bleeding, there is often a telltalevolcano on the septuma tiny clot that if gently brushed begins to bleed. Ifthis is the case, the vessel can usually be controlled by cautery.

Cautery

There are two main methods of cautery. Chemical cautery is a simple procedurein which a silver nitrate stick reacts with the mucosal lining to produce localchemical damage. For maximal effect apply the stick in decreasing concentriccircles around the bleeding vessel.

Electrocautery and diathermy need more specialist equipment and are indicatedif silver nitrate does not control the bleeding. Electrocautery is the application ofan instrument heated by direct high frequency electrical current. Diathermy alsouses high frequency current, but the current passes through the patient. The

instrument forms one electrode, the other is a moistened pad applied to thepatients body. At this stage involve an ear, nose, and throat surgeon to showyou how it is done.

These measures work for most simple epistaxes. Occasionally, however,bleeding continues from a source somewhere out of view in the back of the nose.At this stage you and the patient will be pretty fed up, so now is the time toformally pack the nose with a nasal tampon and refer to the ear, nose, andthroat team for further assessment.

Scenario 3A 75 year old woman presents with epistaxis. She has well

controlled atrial fibrillation and takes warfarin. The bleeding is not controlled bypressure, and the bleeding point cannot be seen on anterior rhinoscopy.

In this case anticoagulation contributes to continued haemorrhage. Warfarin iscommonly used in atrial fibrillation to prevent sequelae of stroke, pulmonaryembolism, and so on. The international normalised ratio and drugs should bereviewed because it is common for patients taking warfarin to be outside thetherapeutic range because of drug interactions or confusion about the correctdose of anticoagulant. As well as further measures to control the bleeding, thesepatients should be resuscitated and blood taken for full blood counts, clottingscreen, and a group and save.

Take greater caution for elderly patients with comorbidities. Assess the patienttaking into account the potential contraindications of treatment and the effectsof and effects on pre-existing conditions. This is true in all disciplines ofmedicine.

Nasal packing

The nose can be packed with a variety of materials,w4 but they all try to provide atamponade effect at the bleeding point. Before trying to pack a nose, rememberthat the floor of the nose goes straight back, not up. Awareness of this simplefact will make putting the pack in much easier.

4


5/7

Explain to the patient what you are about to do. Tell him or her that it will beuncomfortable but only for a few seconds. Clean out the nasal cavity with suctionand by asking the patient to blow the nose. Lift the tip of the nose with thethumb. Push the pack in along the floor of the nose until it is fully inserted (fig 5).Some packings need gentle inflation with 5 ml saline or water. Occasionally

putting a pack in can be difficult because of anatomical constraints in the nosefor example, a deviated nasal septum. If this is the case ask for help from ear,nose, and throat department.

Pushing the pack up towards the roof of the nose is uncomfortable for thepatient. The lack of room means that you wont be able to get the pack all theway in. In the United Kingdom standard practice is to admit the patient to theward for overnight care after nasal packing. This is usually the responsibility ofthe ear, nose, and throat team.w5

Fig 5The correct angle of insertion of the nasal pack (90)

Scenario 4A 45 year old man presents to the emergency department withheavy epistaxis. On examination the patient has small red spots on his face andtorso. On questioning he has had recurrent nosebleeds all his life and his fatherdied of an upper gastrointestinal bleed aged 55.

The spots on the mans body and his family history are evidence of hereditary

haemorrhagic telangiectasia. This is an autosomal dominant disorder thatmanifests as telagiectases of the skin and mucous membranes andarteriovenous malformations. Larger telangiectases can affect the nasopharynx,central nervous system, lung, liver, spleen, and urinary and gastrointestinaltracts. Epistaxis is the most common presentation. Carry out normal proceduresto stop bleeding, but inform the ear, nose, and throat team early for ongoingcare.

Surgery

If a patient continues to bleed after packing, surgery is indicated.w6 Methods suchas septal surgery and arterial ligation may be used. Septal surgery may be

necessary if a large septal spur is present, preventing visualisation of the nasal

5


6/7

cavity and packing. Arterial ligation may be necessary, particularly for posteriorepistaxis.

The most commonly ligated vessel is the sphenopalatine artery, which suppliesblood to much of the posterior two thirds of the nose. The artery can be located

endoscopically by raising a flap of mucosa off the lateral nasal wall beneath themiddle turbinate. Once located, the vessel can be diathermied or clipped. Formore anterior bleeds the anterior ethmoid artery can be approached externallythrough a small incision in the medial wall of the orbit.

Embolisation

Rarely a patient may not respond to surgical attempts to control bleeding or maynot be fit enough for a general anaesthetic. Embolisation entails the introductionof embolic material to reduce or completely obstruct blood flow. Under x rayscreening, a cannula is inserted into the artery suppling the affected area, andoccluding material is injected, such as microspheres, metallic coils, or polyvinyl

alcohol foam. In this situation it is sometimes possible to enlist the help of askilled interventional radiologist to embolise the offending vessel. However, thisis highly specialised care and often requires transfer to a tertiary centre.

Summary

As for the management of many common conditions consensus on exactprotocol may vary depending on a doctors experience and beliefs. However, thisarticle is intended to provide a basis from which junior doctors can work (fig 6).

6


7/7

Fig 6Management algorithm

http://archive.student.bmj.com/issues/08/05/education/212.php

Samuel J Cartwrightfoundation year one doctorBroomfield Hospital, Chelmsford

[email protected]

Jonathan J Morrisfoundation year one doctorSwansea Hospital, SwanseaDarren Pinderconsultant in ear, nose, and throat surgeryFootscray Hospital,

Melbourne, Australia

Student BMJ 2008;16:212-214 | 17

7
http://archive.student.bmj.com/issues/08/05/education/212.phpmailto:[email protected]://archive.student.bmj.com/issues/08/05/education/212.phpmailto:[email protected]

Documents

Managing Nosebleeds