Emergency Evaluation and Management of Epistaxis

Simplified management of epistaxis

ABSTRACT

Primary care, urgent care, and emergency department providers periodically treat epistaxis, either as recurrent nosebleed or an acute persistent episode. Silver nitrate application to the decongested and anesthetized nasal mucosa addresses the former in most cases. The plethora of commercial nasal packing devices testifies to the discomfort, technical difficulty, and frustration associated with traditional gauze-packing methods. Inflatable anterior nasal balloon packs reliably control most nosebleeds. Addition of a Foley catheter nasopharyngeal balloon pack manages most posterior epistaxis. Cautery and the two packing techniques mentioned above should treat most cases not requiring otolaryngology consultation or interventional radiology. Appropriate anesthetic and analgesics lessen the unpleasantness for both the patient and the provider. Topical moisturizing facilitates mucosal healing. Oxymetazoline 0.05% nasal spray provides the patient means to address rebleeding after discharge from treatment.

Epistaxis: some aspects of laterality in 326 patients

Lateralization of primary epistaxis was prospectively studied in 326 patients at Radebeul Elblandklinikum. The male-female-ratio was 1.3:1. A slight dominance of the right side (45% right vs. 39% left) was found in all patients. Further analyzed were the relationship to the localization of bleeding (anterior or posterior), the age and possible causes or risk factors. Nose bleeding from the posterior nasal portion appears to be statistically significantly higher than on both sides of anterior epistaxis. No statistically significant age dependence of laterality of epistaxis was observed in the age groups which we selected. However, nosebleed appears more frequently in women under the age of 50 years in both nostrils. With identified risk factors, idiopathic epistaxis occurs more frequently on the right side than does nosebleed. Mechanical trauma (intranasal sprays or nose picking) is a possible factor explaining the dominance of epistaxis on the right side, especially in idiopathic cases.

Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome

OBJECTIVES

To assess impact of site of idiopathic epistaxis on adult patient management and its association with patient demographics and co-morbidities.

METHOD

The site of epistaxis, patient data, their management and outcomes prior to discharge was recorded prospectively for 100 consecutive eligible adult patients.

RESULT

Fifty three patients had anterior and 47 patients had a posterior site of bleeding. The site of epistaxis was not related to the patient s age, medical condition or medication.

CONCLUSION

Most patients with epistaxis can be controlled with nasal cauterisation. However, patients with posterior epistaxis are more likely to need hospital admission, are twice as likely to require nasal packing, and stay in hospital longer. There appears to be no link between the site of epistaxis and patient factors.

Epistaxis

Epistaxis is a frequent complaint, and may often cause great anxiety in patients and clinicians. Epistaxis results from the interaction of factors that damage the nasal mucosal lining, affect the vessel walls, or alter the coagulability of the blood, and which may be categorized into environmental, local, systemic and medication related. The knowledge of the first aid treatment of epistaxis is very poor, amongst not only the public, but also health professionals. Immediate emergency department management of epistaxis depends on prioritized assessment and treatment, including resuscitation if necessary, together with the application of relatively simple otolaryngological techniques. There is little high quality evidence regarding routine, alternative or adjunctive treatments.

Comparison of nasal tampons for the treatment of epistaxis in the emergency department: A randomized controlled trial

STUDY OBJECTIVE

Nasal tampons are commonly used to stop bleeding, yet their insertion is painful. We compare the pain of insertion and removal of 2 commonly used nasal tampons.

METHODS

This was a prospective randomized controlled trial in 1 urban and 1 suburban emergency department (ED). Subjects were a convenience sample of adult ED patients with active epistaxis requiring insertion of a nasal tampon, regardless of coagulation status. Pretreatment of the nasal mucosa was performed using an aerosolized lidocaine-Neo-Synephrine combination. Patients were randomized to tamponade with a single Rapid Rhino or Rhino Rocket nasal tampon. The pain and ease of insertion and success of tamponade were recorded. Tampon removal was performed after 1 to 3 days, and the pain and ease of removal, as well as the presence of any bleeding, were noted. Patients rated pain of insertion and removal on a previously validated 100-mm visual analogue pain scale (100=worst pain). Physician ease of insertion and removal was recorded on a 5-point Likert scale. Continuous data are presented as means and 95% confidence intervals (CIs).

RESULTS

We evaluated 40 patients evenly distributed between study groups and sites. Median patient age was 61 years (interquartile range 48 to 79 years), and 33% were female patients. Coagulopathy was present in 10 (25%) patients. Baseline characteristics were similar in both treatment groups. The mean pain of insertion of the Rapid Rhino (30 mm, 95% CI 18 to 41 mm) was significantly less than with the Rhino Rocket (48 mm, 95% CI 34 to 61 mm; mean difference 18 mm, 95% CI 1 to 35 mm). The mean pain of removal of the Rapid Rhino (11 mm, 95% CI 1 to 21 mm) was also lower than with the Rhino Rocket (23 mm, 95% CI 13 to 33 mm; mean difference 12 mm, 95% CI -1 to 25 mm). The Rapid Rhino was also easier to insert and remove and had a lower incidence of recurrent bleeding after removal than the Rhino Rocket. Rates of successful tamponade were similar in the 2 groups.

CONCLUSION

The Rapid Rhino nasal tampon is less painful to insert and easier to remove than the Rhino Rocket, whereas both are similarly effective at stopping nosebleeds.

Hemotympanums secondary to spontaneous epistaxis in a 7-year-old

Hemotympanum is a well-known physical finding most often associated with basilar skull fractures and therapeutic nasal packing. A literature review demonstrated only five cases of hemotympanum associated with spontaneous epistaxis in adults. To our knowledge, there have been no reported cases in children. We present a case of a 7-year-old child with bilateral hemotympanums secondary to spontaneous epistaxis.

Posterior epistaxis: clinical features and acute complications

STUDY OBJECTIVE

To describe the clinical features, evaluate the incidence of serious complications, and identify factors associated with rebleeding in adults with acute posterior epistaxis.

DESIGN

Retrospective chart review.

SETTING

University-affiliated community teaching hospital.

PARTICIPANTS

We studied 88 episodes of posterior epistaxis in 81 patients (mean age, 64.3 years; range, 27 to 96 years) who were treated in the emergency department and hospitalized during a 6-year period. Inclusion criterion was active hemorrhage into the posterior pharynx without identifiable anterior bleeding or severe nasal hemorrhage refractory to anterior packing. Patients with anterior epistaxis were excluded.

RESULTS

Posterior epistaxis accounted for 5% of all cases of epistaxis. The most common factors associated with posterior epistaxis were a history of hypertension in 39 patients (48%) and previous epistaxis in 30 (37%). Of 57 patients who reported duration of epistaxis, 39 (68.4%) had nasal hemorrhage for less than 12 hours before ED presentation, and 13 patients (22.8%) had nasal bleeding that lasted more than 24 hours. Bleeding was recorded as moderate or severe for 88% of patients. All patients were treated with posterior nasal packing in the ED (73% with traditional gauze packing, 15% with balloon, and 12% with tampon). After admission, 16 patients (19.8%) required surgical intervention, 17 (21%) experienced acute sinusitis, 10 (12.3%) received blood transfusions, and 3 (3.7%) were intubated. Rebleeding occurred in 24 patients (29.6%), with 13 episodes (44.1%) occurring less than 24 hours after admission. Factors associated with rebleeding were posterior epistaxis described as "severe" (OR, 2.53; 95% CI, .88 to 7.39; chi 2 = 2.84, 1 df, P = .92) and pack removal within 48 hours after admission (OR, 3.07; 95% CI, .98 to 9.88; chi 2 = 3.66, 1 df, P = .056). Factors that failed to predict rebleeding included age, prior hypertension, anticoagulant use, vital signs, and type of posterior pack used (gauze or balloon).

CONCLUSION

Although posterior epistaxis is an uncommon otolaryngologic emergency, many patients experience clinically significant complications. Rebleeding was associated with severe posterior epistaxis and pack removal within 48 hours after admission.

Myocardial infarction associated with inappropriate use of topical cocaine as treatment for epistaxis

A case of a 57-year-old man with hypertension and stable angina, on aspirin therapy, who was treated for epistaxis with intranasal cocaine, and who subsequently suffered a non-Q wave myocardial infarction is reported. Of note, the cocaine was administered in a manner which differs from that advocated in standard references. Specifically, intranasal packing soaked with 4% cocaine was left in place with continuous nasal mucous membrane contact over 5 to 6 hours. The authors speculate that myocardial infarction occurred on the basis of coronary artery spasm. This case should alert practitioners to myocardial ischemia occurring as a complication of the therapeutic use of intranasal cocaine for the treatment of epistaxis.

Practical management of epistaxis

Epistaxis is a very common presenting symptom of patients seen in the emergency room or the physician's office. An understanding of the nasal anatomy and physiology is important for proper treatment of these patients. New methods of treatment are discussed briefly.