Clinical outcome of patients with epistaxis treated with nasal packing after hospital discharge

The Packed Epistaxis Patient: Risks of Rebleeding? A Pilot Study to Inform Outpatient Management of Packed Patients

OBJECTIVE

Current common practice for patients with idiopathic epistaxis which requires nasal packing is to admit as an in-patient for overnight observation. Anecdotally, many patients do not re-bleed, so admissions may be unnecessary. Several factors have been suggested to be associated with an increased risk of re-bleeding, such as hypertension, anticoagulant use, and male gender. We set out to investigate these factors, to create a local guideline to identify patients who may be safe to discharge with a pack in situ.

METHODS

We collected the data on the most recent admissions in our department, who each received a non-absorbable nasal pack for idiopathic epistaxis (n = 100). Data points included age, gender, anticoagulation status, and comorbidities.

RESULTS

Data from 100 patients were audited. Of those, 13 were found to have re-bled through their packing (13%). Statistically significant predictors of re-bleed were as follows: Male sex (OR = 9.81, P = .048, 95% CI 1.02-94.11), aspirin use (OR = 8.11, P = .047, 95% CI = 1.03-63.79), hypertension (OR = 8.14, P = .040, 95% CI = 1.10-60.26), and age (OR = 0.93, P = .018 95% CI = 0.88-0.99).

CONCLUSION

Re-bleed in patients managed with non-absorbable packing for idiopathic epistaxis is uncommon. Risk factors may include male sex, hypertension, and aspirin use. ENT departments nationally may consider discharging patients' home with pack in situ, for removal as an outpatient, in the absence of these risk factors.

Knowledge and awareness of the Saudi general public toward epistaxis: a cross-sectional study

Background

Epistaxis is one of the most common ear, nose, and throat (ENT) emergencies that present to the emergency or primary care centers.

Study aim

This study aimed to assess the knowledge of the Saudi general public toward epistaxis.

Methods

This study adopted a cross-sectional analytical study design. The questionnaire link was distributed using social media channels. The participants were adult Saudi nationals that live in Saudi Arabia. The data was collected using a self-administered questionnaire that assessed knowledge related to epistaxis. The knowledge score was calculated using the 10 knowledge evaluation questions. Each correct response was assigned a value of "one." The scores ranged from "zero" to "ten," with higher scores signifying greater knowledge. A percentage score was computed, and the participants' knowledge was classified as poor (% score: ≤50%), moderate (% score: 51 to 70%), and good (% score: 71 to 100%). Statistical Package for Social Sciences (SPSS) version 26 was used for statistical analysis.

Results

The study included 452 participants of whom 70.1% were females. Married individuals comprised 60.8% of the sample. The prevalence of self-reported epistaxis was 43.6% in the last 6 months. Among the participants, 42.9%, had "Poor" knowledge score, followed by 39.6% who had "moderate" score, and 17.5% had "Good" score. These results show that most participants had poor to moderate knowledge, with a minority demonstrating a good level of knowledge. All demographic variables have significantly influenced the adequacy of knowledge about epistaxis. Furthermore, participants who believed that the general public has insufficient knowledge on epistaxis had a significantly lower knowledge score (p = 0.001).

Conclusion

The present study found a non-satisfactory, low-to-moderate knowledge level of the Saudi general public toward epistaxis. We propose emphasizing public knowledge and education about first aid for epistaxis because proper first aid can minimize significant complications when done properly.

Awareness of First-Aid Management of Epistaxis Among Individuals in Al-Ahsa Region

Introduction Epistaxis is among the most common emergencies in the Ear, Nose, and Throat department. The vast majority of these patients are treated with basic first-aid management. Our study aims to assess the awareness of first‑aid management of epistaxis among individuals in the Al-Ahsa region, Kingdom of Saudi Arabia. Materials and methods This is a cross-sectional study conducted among the male and female population in Al-Ahsa, Saudi Arabia, during March 2023, and it included all participants available at the time of the study. All the data were obtained using an online questionnaire. Results The study included 385 participants; 213 (55.3%) were females and 172 (44.7%) were males. Based on the correlation between our variables, 235 (61%) of the participants had a good awareness score while only 150 (39%) had a poor score. Our findings show that 113 (65.7%) of males had a good level of awareness and 122 (57.3%) of females had a good level of awareness regarding epistaxis. Participants who had gone through an experience of the treatment of any patients with epistaxis had better awareness about first-aid management of epistaxis than participants who had never gone through the experience. Conclusion The knowledge and awareness regarding first-aid management of epistaxis among the general population was satisfactory. However, we should increase the level of knowledge of individuals who did not treat any people with epistaxis because there are many cases of epistaxis in Al-Ahsa However, more integrated educational materials should be available to the general population to improve their overall knowledge. Social campaigns in public areas will enhance the level of knowledge regarding epistaxis management among the general population.

A Systematic Review and Meta-Analysis of the Awareness of and Attitudes Toward Epistaxis

Epistaxis, commonly known as nasal bleeding, ranks among the most prevalent emergencies encountered in otorhinolaryngology. The etiology of epistaxis is multifaceted, arising from both local and systemic factors. In Saudi Arabia, a country with a relatively high prevalence of epistaxis, understanding the level of awareness and attitudes toward first aid management of epistaxis is of paramount importance. This systematic review aims to bridge this knowledge gap by evaluating the awareness of and attitudes toward epistaxis first aid in Saudi Arabia. This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A comprehensive electronic search was executed across PubMed, Google Scholar, and Web of Science databases, encompassing studies published between January 2015 and July 2023. The study included exclusively cross-sectional studies, assessing awareness and attitude toward epistaxis first aid in Saudi Arabia across all populations and studies in English. The 17 selected studies were all published after October 2017, with three published in the year of this systematic review (2023). Sample sizes exhibited substantial variability, ranging from 57 to 2,441 individuals. Despite widespread awareness of epistaxis, the general population often disregards it as a minor health issue. This discrepancy highlights the importance of addressing epistaxis seriously, given the potential for severe bleeding as a medical emergency. The review of 17 studies revealed significant variations in epistaxis awareness levels, influenced by factors such as age, gender, and varying sample sizes. Notably, higher awareness levels were observed in studies involving the general Saudi population and those employing self-administered questionnaires. The average awareness and knowledge of epistaxis and its management among Saudi residents were moderate, with an estimated awareness level of 63%. A large-scale epidemiological survey, considering sociodemographic factors, is recommended to provide a more comprehensive understanding of epistaxis awareness.

Awareness of Epistaxis and Its First Aid Management Among Teachers Working in Schools of Al-Baha Region, Saudi Arabia

Background Epistaxis (nosebleed) is a frequent emergency presentation in the emergency department (ED). Generally, any harm to the nasal mucosa lining can lead the nose to bleed. The etiologies of epistaxis are widely classified as environmental, local, systemic, and medication-related causes. The initial management for epistaxis is first aid. First aid by applying pressure on the nostrils is essential to stop the bleeding and minimize discomfort. This study intends to evaluate teachers' awareness regarding epistaxis first aid management inside schools in Al-Baha region, Saudi Arabia. Methodology A cross-sectional study was conducted among a target of 439 teachers regarding epistaxis first aid management inside schools in Al-Baha region, Saudi Arabia. Data were collected using a structured questionnaire and analyzed using descriptive statistics and a chi-square test. Results Of the teachers, 50.7% had received training regarding epistaxis, while 49.3% had never been trained. Also, 73.3% considered that applying nasal compression may help stop bleeding, while the rest were completely unaware. On further investigation, tilting the head forward would be done by 56.27% of the teachers, while 40.73% said that the head should be tilted back. Of the teachers, 53.3% would go to the emergency if bleeding continued for more than 10 minutes. No association between age, gender, and working area, and training received regarding the management of epistaxis was found (p>0.05), but teachers from a scientific background, as compared to those from a literature background, were able to answer better regarding the management of epistaxis (p<0.05). Conclusion The study highlights knowledge gaps regarding epistaxis first aid management inside schools in Al-Baha region, Saudi Arabia. The research highlights the need for focused training programs and awareness efforts to enhance teachers' knowledge and first aid practices. Addressing misknowledge and mispractices, enhancing the practices and attitudes of healthcare providers toward appropriate feeding practices, and promoting a supportive and safe environment could all contribute to the improvement of quality of life and health among the population of Saudi Arabia.

Parents' knowledge regarding first-aid management of epistaxis in children in Taif, Saudi Arabia

Objectives

Epistaxis among children is considered a scary issue for both the child and the parents. In Saudi Arabia, one third of children suffer from epistaxis. In our study, we aimed to assess the level of knowledge among parents regarding first-aid management of epistaxis in Taif city, Saudi Arabia.

Method

We carried out a descriptive cross-sectional study among parents who visited Alhada Armed Forces Hospital and Prince Mansour Military Hospital between May 2022 and July 2022 in Taif, Saudi Arabia. A questionnaire with 17 questions was distributed among the participants. We excluded parents with children who were older than 18 years.

Results

A total of 502 parents were included in the study. About two thirds (67.5%) of parents had a moderate level of knowledge and around one third (30.9%) showed a good level of knowledge regarding epistaxis first aid. Furthermore, higher knowledge scores were found among parents who had epistaxis previously (P = 0.026), who attended a course on first aid (P = 0.002), and who were aged more than 35 years (P = 0.017).

Conclusion

Our study demonstrated that most Saudi parents had a moderate level of knowledge regarding first-aid management of epistaxis. Additionally, several factors, such as the number of children, age, those attending first-aid courses, and experience treating others with epistaxis, were associated with the level of knowledge among parents. Further larger studies are required among Saudi parents to examine the knowledge, practice, and related factors regarding first-aid management of epistaxis.

Clinical Practice Guideline: Nosebleed (Epistaxis)

OBJECTIVE

Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.

PURPOSE

The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

Treatment Options for Severe Epistaxis, the Experience of Coltea ENT Clinic

OBJECTIVES

The study presents the experience of the Coltea ENT Clinic with the most common emergency in ENT pathology.

RESULTS

The study group comprises 51.24% women and 48.76% men with 73.14% of patients (177) coming from urban areas and the remaining 26.86% (65) from rural areas. The total number of days of hospitalization is 1411, representing an average of 5.83 days / patient. Epistaxis was anterior in 80.17% of cases (194 patients) and antero-posterior in 19.83% (48 patients). 132 patients, representing 54.55% presented elevated blood pressure whereas liver and hematological disorders are uncommon etiologies. Therapeutic interventions are mostly non-surgical 207 (85.54%), the remaining 35 cases (14.46%), requiring surgery.

CONCLUSIONS

Epistaxis associated with high blood pressure is found in 54.55% of the study group. In 38.02% of cases the etiology cannot be determined. Pluri-factorial etiology is common. The most difficult to control were the cases with epistaxis of hepatic etiology, in which cases the surgical solution was required.

The Efficacy of Ankaferd Blood Stopper in Heparin-Induced Hemostatic Abnormality in a Rat Epistaxis Model

Objective. To assess the in vivo hemostatic effect of Ankaferd Blood Stopper (ABS).

Study Design. An experimental study of an animal anterior epistaxis model.

Setting. A tertiary care university hospital.

Subjects and Methods. Wistar rats were randomized into 4 groups of 7 each: group 1, control, no pretreatment, irrigated with saline; group 2, no pretreatment, irrigated with ABS; group 3, control, heparin pretreatment, irrigated with saline; and group 4, heparin pretreatment, irrigated with ABS. In all groups, a standardized rat epistaxis model was obtained by cutting the anterior nasal septal mucosa. To control bleeding, compressive dressings were placed after instilling 1 mL of either ABS or saline to the bleeding area. The hemostasis time and amount of nasal bleeding were measured in all groups to compare the treatments without and with ABS.

Results. Without heparin pretreatment, ABS shortened the hemostasis time by 1.57 minutes ( P = .003) and reduced the amount of the bleeding by 0.35 g ( P = .006). With heparin pretreatment, ABS shortened the hemostasis time by 2.86 minutes and reduced the amount of the bleeding by 0.49 g (both P = .002).

Conclusion. ABS irrigation was more effective than saline irrigation for treating anterior epistaxis hemostasis in animals using a compressive dressing with or without heparin pretreatment.