Epistaxis (i.e., nosebleed) is a very common complaint among primary care patients. Because the blood supply to the nasal cavity originates in the carotid arteries, epistaxis may produce profuse bleeding. More than 90% of nosebleeds originate from the anterior part of the nose, usually from Kiesselbach's plexus on the nasal septum. This chapter focuses on the more common anterior bleeds. Kiesselbach's plexus is readily accessible to objects inserted into the nose. The presence of nasal trauma, recent use of intranasal agents, presence of a foreign body, recent infection, exacerbated allergy, and no sensation of blood flowing down the back of the throat all suggest an anterior site of bleeding.
Local and systemic disorders may cause nosebleeds (Table 55-1). In a patient older than 40 years of age, bleeding is often posterior and may be associated with systemic disease. The site of bleeding should be identified in all patients, even those in whom the bleeding has stopped, because the severity of the problem and the treatment options vary by site. If serious bleeding exists, the highest priority is to secure the patient's airway, breathing, and circulation. One third of children presenting with recurrent epistaxis have a diagnosable coagulopathy.
TABLE 55-1. COMMON CAUSES OF EPISTAXIS
When a patient presents with epistaxis, obtain a brief history to determine the duration and severity of bleeding and the presence of any contributing factors. If bleeding is severe, consider getting a complete blood cell count (CBC), prothrombin time and partial thromboplastin time (PT/PTT), blood type, and screen. Determine if the bleeding originates in the anterior or posterior part of the nasal cavity. It may be difficult to determine the source of the bleeding because clots may be present, and blood can reflux into the unaffected side. Have the patient blow his or her nose to dislodge clots. Suction with a Fraser tip may be helpful. Adequate lighting and suction are essential to a good physical examination. The physical examination should include vital signs, evaluation for orthostasis, and inspection of the oral cavity and nasopharynx.
Anterior epistaxis usually can be stopped by direct pressure, use of vasoconstrictors, simple cautery, and packing. Direct pressure is often the first therapy applied, typically using the closed hand technique. It provides firm compression and makes it easier for the patient to maintain his or her grip. Time the nasal compression (5 to 10 minutes), because patients usually underestimate the elapsed time.
If direct pressure is unsuccessful, apply a combined vasoconstrictive agent and anesthetic (Table 55-2) using a spray bottle, atomizer, or pledget. A moistened pledget provides better contact with the nasal mucosa while also providing a local tamponade effect. Cocaine provides excellent vasoconstriction and anesthesia, but it is rarely available.
TABLE 55-2. VASOCONSTRICTIVE AND ANESTHETIC AGENTS FOR EPISTAXIS
Chemical cautery with silver nitrate sticks is effective treatment for minor anterior nasal bleeding. First, control bleeding using vasoconstrictors or direct pressure, or both, because it is difficult to cauterize an actively bleeding area by chemical means alone. Electrical and thermal cautery also may be used, but these are no better at hemorrhage control than chemical cautery. Battery-powered, disposable heat cautery devices are difficult to control for the depth of cautery, and significant injury can occur.
Anterior nasal packing should be considered when the previous methods fail after three attempts. Prepare the nasal cavity with a combined vasoconstrictor and anesthetic agent. (Table 55-2). The nasal cavity is packed using strips of petrolatum- or iodoform-impregnated gauze or an appropriate commercial device. If nasal packing does not control isolated anterior bleeding, the anterior pack should be reinserted to ensure proper placement. Leave anterior packs in place for 48 hours. Ask the patient to report any fever or recurrent bleeding and to return immediately if bleeding recurs or if there is a sensation of blood trickling down the back of the throat.
Commercial products have been specifically developed to make the insertion of an anterior nasal pack easier and more comfortable for the patient. The Merocel nasal sponge (Merocel Corp., Mystic, CT) is a dehydrated, spongelike material that expands on contact with moisture. The Merocel sponge may be more comfortable than a balloon or gauze packing. It has been reported that the efficacy of this device is comparable to other methods. Gelfoam packs also can be used.
Complications from direct pressure, chemical cautery, and anterior nasal packing are rare. Continued bleeding is always a possibility, and infections may occur. Septal perforations have been reported with overzealous use of chemical cautery. Complications from anterior nasal packing include dislodgement of the packing, recurrent bleeding, and sinusitis. Patients discharged with nasal packing should be given antibiotics to prevent the rare complication of toxic shock syndrome. Antibiotic choices include cephalexin (250 to 500 mg four times daily), amoxicillin-clavulanate (250 to 500 mg three times daily), clindamycin (150 to 300 mg four times daily), or trimethoprim-sulfamethoxazole DS (twice daily). If the patient complains of choking or a foreign body sensation in the back of the throat, look for layers of an anterior nasal pack that have fallen backward into the nasopharynx. If there is evidence of continued bleeding after the insertion of an anterior pack, consider the possibility of inadequate packing or a posterior bleeding site. If attempts to control the bleeding fail, consult an otolaryngologist.
If the bleeding is controlled, instruct the patient not to manipulate the external nares or insert foreign objects or fingers into the nasal cavity. Petrolatum or triple antibiotic ointment may be applied to dry nasal mucosa with a cotton-tipped applicator once or twice each day for several days. Have patients avoid aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) for 3 or 4 days. If bleeding recurs, the patient should use home measures such as over-the-counter nasal sprays or direct pressure for 5 to 10 minutes before returning for medical care. If bleeding continues after repeating compression twice more, have the patient seek immediate medical help.
Posterior packing may be required for uncontrolled posterior bleeding. Posterior padding requires skill and practice in the face of vigorous bleeding and is best performed in emergency departments or hospital settings by physicians experienced in such insertion.
Kiesselbach's plexus is a complex anastomosis of arterioles in the superficial region of the nasal mucosa on the nasal septum. It is fed by the septal branches of the anterior ethmoid (AE), posterior ethmoid (PE), sphenopalatine (S), superior labial (SL), and greater palatine (GP) arteries.
(1) Arterial anatomy of the nasal septum.
Apply pressure using the closed hand method. Vasoconstrictors may be used in conjunction with or independent of directed pressure.
(2) Apply pressure using the closed hand method.
PITFALL: Using two fingers to pinch the nose (rather than the closed hand method) makes it more difficult to maintain a grip and keep adequate pressure on the nose.
If anterior epistaxis cannot be controlled with vasoconstrictors or direct pressure, or both, chemical cautery may be attempted. Prepare the nasal cavity with combined vasoconstrictor and anesthetic agent (Table 55-2). After the bleeding has stopped, dry the mucosa, and cauterize it by touching the bleeding source with the tip of a silver nitrate stick for 10 to 15 seconds. Wipe away any residual silver nitrate and apply antibiotic ointment if desired.
(3) Chemical cautery can be used if anterior epistaxis cannot be controlled with vasoconstrictors or direct pressure.
Gauze packing may be used for resistant anterior epistaxis. Prepare the nasal cavity with combined vasoconstrictor and anesthetic agent (Table 55-2). Visualize the nasal cavity using a nasal speculum to ensure proper gauze placement.
(4) Gauze packing can be used for resistant anterior epistaxis.
PITFALL: Blind packing often results in loose placement of the gauze and inadequate compression. Inadequate packing is probably the most common cause of treatment failure.
Using bayonet forceps, grasp one end of a long strip of ¼-inch petrolatum or iodoform gauze saturated with antibiotic ointment approximately 2 to 3 cm from its end (Figure 5A). Allow the end to double over, and insert it through the nasal speculum to the posterior limit of the floor of the nose (Figure 5B).
(5) With bayonet forceps, grasp one end of a long strip of ¼-inch petrolatum gauze saturated with antibiotic ointment, allow the end to double over, and insert it through the nasal speculum to the posterior limit of the floor of the nose.
Withdraw the bayonet forceps and nasal speculum. Reintroduce the nasal speculum on top of the first layer of packing. Grasp another loop of gauze with the bayonet forceps. Insert it on top of the previous course using an “accordion” technique so that part of each layer lies anterior to the previous layer, preventing the gauze from falling posteriorly into the nasopharynx. With each layer, use the forceps to gently push the underlying strip downward.
(6) Withdraw the bayonet forceps and nasal speculum, and reintroduce the nasal speculum on top of the first layer of packing.
Continue to repeat until the entire nasal cavity is filled with layers of packing material. Observe the patient for 30 minutes to make sure that adequate hemostasis has been achieved.
(7) Continue to layer gauze using an “accordion” technique until the entire nasal cavity is filled with layers of packing material.
Alternatively, the Merocel sponge may be used for anterior packing. The sponge absorbs the blood and secretions and quickly expands to provide a good tamponade effect. Insert the sponge rapidly, because it will start to expand almost immediately on contact, unless it is coated with a water-soluble antibiotic cream.
(8) Alternatively, you can use a Merocel sponge for anterior packing.
PITFALL: If there is inadequate expansion after insertion, inject sterile saline using a syringe and intravenous catheter to rehydrate the sponge.
INSTRUMENT AND MATERIALS ORDERING
Suction tips and nasal speculums may be obtained from most national supply houses such as
http://www.AllHeart.com-Professional Appearances, Inc., 431 Calle San Pablo, Camarillo, CA 93012 (fax: 805-445-8816;http://www.store.yahoo.com/allheart/index.html) or from MD Depot, 7590 Commerce Court, Sarasota, FL 34243 (phone: 888-355-2606; fax: 800-359-8807; http://www.mddepot.com). Merocel sponges may be obtained from Invotec International, 6833 Phillips Industrial Boulevard, Jacksonville, FL 32256 (phone: 800-998-8580; http://www.invotec.net/pva_plus.html).
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