Epistaxis

1. Through history and/or physical examination, assess the hemodynamic stability of patients with epistaxis.

2. While attending to active nose bleeds, recognize and manage excessive anxiety in the patient and accompanying family.

3. In a patient with an active or recent nosebleed, obtain a focused history to identify possible etiologies (e.g., recent trauma, recent respiratory tract infection, medications).

4. In a patient with an active or recent nosebleed:

   1. Look for and identify anterior bleeding sites

   2. Stop the bleeding with appropriate methods.

5. In a patient with ongoing or recurrent bleeding in spite of treatment, consider a posterior bleeding site.

6. In a patient with a nosebleed, obtain lab work only for specific indications (e.g., unstable patient, suspicion of a bleeding diathesis, use of anticoagulation).

7. In a patient with a nose bleed, provide thorough aftercare instructions (e.g., how to stop a subsequent nose bleed, when to return, humidification, etc.)

Hospital

1. ABC, Vitals

   • Consider definitive airway, fluid resuscitation

   • Consider labs if unstable or suspect coagulopathy: CBC, INR, Blood type, cross match, consider LFT/creat

   • Consider wearing gown, gloves, mask, face shield

2. Suction (Blow nose to remove clots or use angled Frazier 10-12F suction)

3. Vasoconstriction

   • Topical or soaked cotton vasoconstrictors x 5-10 mins (eg. lidocaine, phenylephrine, epinephrine, oxymetazoline, xylometazoline)

   • Consider Tranexamic acid through atomizer and 15 minutes of external compression

4. Cautery if bleeding source visible by nasal speculum

   • Suction and dry prior

   • Silver nitrate until gray precipitate

     • Only cauterize one side of septum (if both sides cauterized - risk of perforation)

   • Electrocautery usually done by ENT after local anesthesia

5. Packing

   • Anterior packing (traditional vaseline gauze, compressed sponge/tampon, balloon, absorbable materials)

     • Admission/ENT consult if bilateral packing needed

   • Posterior packing (posterior source suggested in failure to visualize anterior source, bleeding from both nares, and blood in posterior pharynx)

• • 1. Analgesia

    2. Double balloon catheters or foley with 30mL balloon

    3. Admission to monitor for hypoxia

5. • Leave packing 1-3 days prior to removal, can consider prophylactic antistaphylococcal antbiotics to prevent Toxic Shock Syndrome

     • Consider F/U ENT 48-72h

6. Consider coagulopathy

7. Refer to ENT/surgery for endoscopic ligation/embolization in severe cases

Prevention of re-bleeding

• Avoid activities

  • Blowing/picking nose

  • Open mouth when sneezing

  • Heavy lifting/strenuous exercise

  • Drinking alcohol/hot drinks

  • Stop smoking/alcohol/cocaine

• Nose care

  • Humidifier

  • Water-based lubricating gel (eg. Secaris) gently applied by Q-tip TID x 10d for dryness

    • Note: Inhaling petroleum jelly for prolonged periods can potentially cause lung inflammation (lipoid pneumonia)

  • Consider (low evidence) topical antibacterial (mupirocin) or bacteriostatic (bacitracin) ointment 

  • Direct nasal sprays away from septum

• Consider holding aspirin/antiplatelets x 6 days, NSAIDs x 3 days