QuestionSBA
QuestionChoice
This is not indicated at this stage as the patient is haemodynamically stable
31835
c
Urgent transfer to ITU
QuestionChoice
This is only indicated if the patient has had nasal packing
31836
d
Refer to ENT for admission for observation
QuestionChoice
This would be the next step if the bleeding stopped with first aid measures
31837
e
Naseptin cream
QuestionChoice
Nasal packing should only be considered in primary care if nasal cautery has been ineffective or the bleeding point cannot be seen
31834
b
Nasal packing
QuestionChoice
This is the next step in managing epistaxis if first aid measures have not worked and given that the appropriate expertise and facilities are available
31833
a
Nasal cautery
QuestionComment
im sorry but no. you would pack and send to A+E for cauterising
6561
QuestionComment
they're already in A&E
7317
User
subscriber
Dermis Cystic
QuestionComment
im sorry but no, cautery goes ahead of nasal packing if an obvious bleeding site is seen and you are in the ED 
10097
User
subscriber
Complement Hypertension
QuestionComment
You're not Dr brighton yet xx
26965
User
subscriber
rock bottom
User
subscriber
Dr Brighton
Concept
Chapter
# Summary
 
Epistaxis refers to nosebleeds, which are a common condition ranging significantly in severity. Many are mild and self-limiting with simple first-aid, however larger bleeds may be life-threatening and require rapid intervention and resuscitation. Contributing factors include trauma (e.g. nose-picking), inflammation, drug use (e.g. cocaine), recent surgery, tumours and bleeding diatheses. Management of epistaxis involves a stepwise approach starting with direct pressure on the cartilaginous part of the nose, cautery, nasal packing, followed by interventions such as arterial embolisation or ligation if bleeding is refractory to other treatments. 
 
# Definition
 
Epistaxis refers to bleeding from the nose - this usually originates from the anterior nasal septum (Little's area and Kiesselbach's plexus specifically) but around 10% of cases are posterior, originating from branches of the sphenopalatine artery. 
 
# Aetiology
 
Most cases of epistaxis are mild and self-limiting, with no specific underlying cause identified. Factors that may contribute to epistaxis include:

- Trauma (e.g. nose-picking, blunt trauma, septal perforations and foreign bodies in the nose)
- Oxygen via nasal cannulae (causes drying and irritation of the nasal mucosa)
- Recent ENT or maxillofacial surgery
- Tumours, either malignant (e.g. squamous cell carcinomas) or benign (e.g. angiofibromas)
- Inflammation (e.g. rhinosinusitis, nasal polyps)
- Alcohol excess
- Illicit drug use e.g. snorting cocaine 
- Medications such as nasal steroids
- Vasculitides (e.g. granulomatosis with polyangiitis)
- Bleeding diatheses (e.g. thrombocytopenia, Von Willebrand disease, haemophilia, antiplatelet or anticoagulant medications)
- Environmental factors e.g. inhaled irritants, temperature and humidity

# Signs and symptoms

The major symptom is nasal bleeding - other signs and symptoms may include:

- Bleeding down the throat (which may present as haemoptysis or haematemesis) - may signify posterior epistaxis
- Bleeding from both nostrils is another sign of possible posterior epistaxis
- Signs and symptoms of haemodynamic instability if blood loss is significant (e.g. tachycardia, pallor, syncope)
- Signs and symptoms of an underlying cause (e.g. nasal obstruction and rhinorrhoea may indicate a tumour or nasal polyps)

# Investigations

In most cases of nosebleeds, no investigations are required.

If bleeding is significant, a **venous blood gas** and **FBC** should be done to look for anaemia and thrombocytopenia, a **clotting screen** looking for coagulopathy and a **group and save** or **crossmatch** if blood transfusion is required.

Investigations may also be required if an underlying serious cause is suspected, e.g. imaging or flexible nasendoscopy for a suspected tumour, or specific blood tests for bleeding disorders such as Von Willebrand disease.

# Management

- The first step in management is **direct compression**.
- The patient should sit forward (minimising bleeding into the nasopharynx), breathing through their mouth, and pinch the cartilaginous part of the nose for 10-15 minutes. 
- Sucking ice cubes, cold drinks or placing an ice pack on the back of the neck can help to reduce bleeding.
- This is sufficient to resolve the majority of anterior epistaxis.
- A **topic antiseptic** (e.g. Naseptin or mupirocin) may be prescribed to reduce crusting and rebleeding.
- If direct compression does not resolve the epistaxis and a bleeding point can be visualised, **cautery** may be performed. 
- This involves applying a local anaesthetic spray with a vasoconstrictor (e.g. lidocaine with phenylephrine) to temporarily halt bleeding, then apply silver nitrate (chemical cautery) or electrocautery to the area. 
- Only one side of the septum should be cauterised to avoid perforation.
- If a bleeding point cannot be visualised or bleeding continues despite cautery, **nasal packing** may be used. 
- The most common devices used are nasal tampons (e.g. Merocel) or inflatable packs (e.g. Rapid-Rhino). 
- Both nostrils can be packed to increase pressure on the area of bleeding.
- In cases of posterior epistaxis, **posterior packing** may be required which may involve insertion of a Foley catheter with the balloon inflated to compress the bleeding area.
- Packing should be left in place for 24-48 hours to ensure bleeding has stopped.
- If bleeding continues despite packing, a **surgical approach** may be required (e.g examination under anaesthesia with ligation of bleeding vessels) or interventional radiology may perform an **embolisation**.
- **Tranexamic acid** should be given to all patients with severe bleeding.
- Antiplatelets and anticoagulants should usually be held - may need speciality input (e.g. cardiology) in difficult cases such as patients with metallic heart valves.
- Anticoagulation may need to be reversed with haematology input if needed.
- Patients who are haemodynamically unstable may need resuscitation and blood transfusion.

# Complications

- Anaemia
- Recurrent epistaxis
- Hypovolaemia
- Aspiration of blood and airway compromise
- Nasal cautery may cause septal perforation
- Nasal packing may lead to sinusitis, septal haematoma or pressure necrosis

# NICE Guidelines

[NICE CKS - Epistaxis](https://cks.nice.org.uk/topics/epistaxis-nosebleeds/)

# References

[ENT UK - Epistaxis Guideline](https://www.entuk.org/_userfiles/pages/files/guidelines/global%20ent%20guidelines/nosebleeds.pdf)
 
[Life in the Fast Lane - Epistaxis](https://litfl.com/a-case-of-epistaxis/)

[Patient UK - Epistaxis](https://patient.info/doctor/nosebleed-epistaxis-pro)
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Nasal cautery is indicated for managing anterior epistaxis when initial measures, such as nasal pressure, are ineffective.
A 24 year old male presents to the Emergency Department with epistaxis which started 1 hour prior to being seen. The nurse practitioner has already applied nasal pressure for 15 minutes. On examination using a nasal speculum, there is an obvious bleeding site in the anterior aspect of the septum. The patient is haemodynamically stable.

What is the next best step in management of this patient's epistaxis?
a