Points to note on the history
- Any history of trauma
- Timing of onset, duration and side of bleed
- Is it continuing to bleed
- Any blood being swallowed, or sensation of blood in the pharynx
- Previous episodes
- PMHx e.g. previous nasal surgery, hypertension, sinusitis
- Recent URTI/rhinitis, TB, sarcoid, wegeners', nose picking, septal defects
- Drug history e.g. anti-hypertensives, steroid nose drops/sprays, aspirin / warfarin
- cocaine, sympathomimetic nose drops, xylometazoline, ephedrine
Points to note on examination
- Any airway compromise?
- Pulse, BP, capillary refill
- Side of bleed
- Presence of obvious bleeding point in Little's area
- Blood in oropharynx/ blood being coughed up or fresh haematemesis
- Epistaxis can be life threatening
- All patients must have baseline observations carried out
- Rapid primary survey then more detailed history and examination
- Patients should be and be reassessed regularly
To examine the nose, if there is clot blocking your view, ask the patient to gently blow the nose, one nostril at a time to clear it. Then, gently, elevate the tip of the nose with one finger, whilst shining a torch into the nasal antrum. This should allow a view of Little's area. Thudicums may be used, and are available in nasal packing packs, or ENT emergency packs.
Any septal deviation should be noted, as well as bony deformity on external inspection (especially in the case of traumatic epistaxis).
The oropharynx should be visualised with a tongue depressor and torch.
- Suit up! "3 Gs": gloves, gown, and goggles.
- Resuscitate your patient first if necessary.
- Quick but comprehensive history (left).
- The patient should be sitting up and bending slightly forwards to prevent blood from tracking into the pharynx.
- Simple measures to stop the bleeding first.
- i.v. access.
- Send blood for FBC, U/E, Clotting, G&S/Xmatch.
- i.v. fluid resuscitation if appropriate.
To stop epistaxis
- Consider Floseal.
- If there is any airway compromise, then formal packing, both anterior and posterior, should be performed without delay (contact ED duty registrar for this ).
- Formal packing can be painful- requires adequate analgesia ( i.e. morphine ) +/- topical anaesthesia.
- If traumatic epistaxis, with an obviously deformed nose, then manipulation of the nose, under local anaesthetic, will help to release tension on bleeding vessels and stem the flow of blood.
- In the case of maxillary fractures causing profuse posterior epistaxis, with airway compromise, then posterior packing will help.
- If this does not work, cautery any clear bleeding point with silver nitrate.
- Apply cocaine and Adrenaline liquid/paste improve view
- It is a local anaesthesia, and sympathomimetic action
- Facilitates examination and may help to stop bleeding
- The next step would be nasal packing
- Leave formal nasal packing (BIPP soaked ribbon gauze) to ENT specialist
- If the patient continues to bleed, or has required packing, then they must be referred to the on-call ENT team.
If you are successful in stopping bleeding
- Observe the patient for 1 hour
- Prescribe Naseptin cream topically to both nostrils tds for one week
- Vaseline used in the same way thereafter may prevent further episodes
- Do not be tempted to cauterise prominent vessels in Little's area, unless they are bleeding, as it does not improve outcome.
- Tell the patient to avoid hot drinks for 24hrs.