Epistaxis

Aetiology

History

- Did bleeding begin unilaterally or bilaterally? -> anterior bleeds tend to start unilaterally and can become bilateral whereas posterior bleeds tend to be bilateral from the beginning 

- General medical history -> particularly systemic conditions, medications (anticoagulants!) and smoking 

- History of easy bruising, prolonged bleeding or recurrent epistaxis  -> consider systemic conditions

- Family history of bleeding disorders

- Note: foreign bodies tend to cause unilateral discharge rather than bleeding

Examination

Before starting make sure you have all equipment prepared including cautery, suction and topical meds

Use the following:
- headlight: allows two free hands
- nasal speculum
- will nearly always require suctioning of blood or clot to allow better view

First you should spray local anaesthetic into both sides
Use suction to remove blood and try to find the bleeding source. Soak a few small cotton balls in local anaesthetic with adrenaline and place it around the bleeding area. Wait for 15 minutes - this will provide anaesthesia and may stop bleeding

Investigations

1. FBC - to assess severity of haemorrhage via the Hb
2. Coagulation screen - especially if on warfarin
3. Blood pressure - can contribute to bleeding

Management

Epistaxis is treated via an escalating management principle - i.e. you try sequential approaches - moving on if you do not succeed in stopping the haemorrhage

NB: this is not appropriate if the bleeding is severe or if there are signs of haemodynamic instability at which point urgent bilateral packing with a device such as a Rapid Rhino is warranted

Escalation
1. Pinching the nose for 10mins (at the soft part not the bone part) +/- sucking on ice
2. Cotton balls soaked in mixture of lignocaine and adrenaline placed around the bleeding area after suctioning to identify bleeding point (this is also used prior to cautery so that the bleeding vessel can be identified). This step can be repeated a number of times
3. Cautery - this is performed using silver nitrate sticks when the bleeding vessel has been identified AND bleeding has stopped. This will be possible in most anterior bleeds.
4. Packing the nasal cavity with Rapid Rhino (see video below) or Merocel (a non-inflatable nasal tampon) for 24 hours
5. If all else fails - bilateral Rapid Rhinos are placed

6. Very rarely arterial ligation and embolisation are performed when the above do not work

Posterior bleeds
These are only able to be diagnosed with careful examination and suctioning
In the past Foley catheters were used but:
1. Now a Rapid Rhino can provide compression to the posterior septum equally well. Occasionally bilateral Rapid Rhinos are needed
2. Endoscopic sphenopalatine artery ligation for persistent bleeding