EMed

Epistaxis

Assessment

Points to note on the history:

  • Any history of trauma
  • Timing of onset, duration and side of bleed
  • Is it continuing to bleed
  • Blood 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 or DOAC that may require reversing

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
  • Rapid primary survey then more detailed history and examination
  • Patients should be and be reassessed regularly

Examination

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.

General advice

  • 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

Management

Correct Epistaxis Instructions
Other than in the above cases, the first line treatment of epistaxis is conservative. Instruct the patient to squeeze hard over Little's area with one hand, whilst putting an ice pack on to their forehead. Instruct them to remain like that for at least 20 minutes, without releasing pressure to see if the bleeding has stopped.
  • 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

  • If relatively minor, examine and start with silver nitrate cautery(below)
  • Consider Flosealif severe
  • If there is any airway compromise, then Rapid Rhino packing, both anterior and posterior, should be performed without delay (contact EM duty registrar for this )
  • 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
  • Note instructions to soak the RapidRhino in water (not saline)
  • 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

Further management

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

Cautery (silver nitrate

Minor bleed with visible culprit vessel on anterior nasal septum/ speculum exam.

  • Choose an appropriate (cooperative) patient
  • Wash hands and wear gloves
  • Establish haemostasis prior to use of silver nitrate stick; achieve with direct pressure, suction to remove any clot
  • Anaesthetise the area to be cauterised with co-phenylcaine spray:
    • Can spray directly onto septum, may be more effective to wet a cotton ball with the co-phenylcaine spray and apply this to the nasal septum (one side only) for 1-2 minutes, then remove and gently pat dry to maximise effectiveness of silver nitrate application
  • Apply a paraffin barrier to enclose the area of treatment prior to performance of the cautery i.e. at entrance to nares:
    • Moisture can cause the silver nitrate to drip and cause grey or black staining of the skin around the nares or upper lip
    • This can be cosmetically troubling for patients
    • If staining does occur, the stain will fade as the skin naturally exfoliates (1-2 weeks); gentle rubbing with some aqueous cream on a cue tip may hasten removal of the stain if used early (for use on intact skin, not the area of cauterised septum
    • Do not rub or apply friction to the area of treatment
  • Wet just the tip of the silver nitrate stick with some sterile water
    • If it is too wet the risk of dripping and staining is increased
    • If there is a pinpoint of active bleeding, the tip will not need to be moistened
  • Note there is no role for AgNO3 for brisk, moderate or severe bleeding
  • Gently roll the applicator tip over the mucosa or at the pinpoint bleeding site until a grey eschar forms or for a maximum of 5 seconds
  • Do not perform prolonged, extensive or bilateral septal cautery (risk of necrosis/perforation
  • Do not extend cautery to normal nasal mucosa
  • Check that the bleeding has stopped: discharge with post cautery advice

Post-cautery

  • Prescribe a nasal antiseptic moisturiser such as Kenacomb®
  • Use paracetamol for discomfort
  • No rubbing or blowing nose for a week
  • Avoid boisterous play / contact sports / heavy lifting for a week
  • Review by GP (post cautery patients do not require ENT follow up

Content by Dr Mohsin Tahir, Dr Íomhar O' Sullivan. Last review Dr 25/03/25.