Tricks of the Trade: Epistaxis Management

Raise your hand if you hate treating nose bleeds! Whenever I see ‘epistaxis’ pop up as a chief complaint on my computer in the emergency department, I head straight for the restroom…maybe by the time I return, another provider will have picked up the chart… Some nose bleeds resolve quickly with just a few sprays of Afrin, but those that don’t can be tricky to treat. Not to mention, patients generally don’t appreciate having tampon-like devices shoved up their nares. Here are a few tips and tricks for treating epistaxis in your practice.

Know the location of the bleed

The first step to treating epistaxis is to identify the source of the bleed. most nosebleeds occur in the anterior portion of the nare. Ask the patient to blow their nose to dislodge any clots prior to examination to increase your chances of visualizing the exact site of the bleed.

Most nosebleeds occur anteriorly. Symptoms of a more serious posterior bleed include bleeding from both nares, hemoptysis, melena, nausea and/or vomiting. Hemodynamic stability must be considered in these patients. For most posterior nose bleeds, nurse practitioners will need to call in backup. An otolaryngologist is typically needed for further evaluation and treatment of posterior epistaxis.

Consider comorbid conditions

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Patients with severe bleeding, patients on anticoagulant therapies, and those with hepatic or renal dysfunction may require additional evaluation and treatment. A CBC and coagulation studies should be drawn to assess the severity of and reason for bleeding. In patients with epistaxis as a result of trauma, consider risk for intracranial bleeding and other complications like facial fractures. Imaging may be necessary to assess for these complications.

Start simple

60 percent of us will have an episode of epistaxis at some point in our lives. Fortunately, of the cases nurse practitioners will treat in their practice, 90 percent resolve with simple intervention. The odds are good you can effectively manage epistaxis in most patients presenting to your practice.

The first step to treating a nose bleed is the application of direct pressure to the anterior portion of the nares. 5 to 10 minutes of direct pressure with a nasal clamp is typically enough to stop bleeding. Patients should keep the head elevated but not hyperextended. Hyperextension may cause bleeding into the pharynx resulting in nausea and possible aspiration.

If the bleed does not resolve with the application of direct pressure alone, apply a vasoconstrictor to the site. A few sprays or Afrin into the effected nostril or placing a piece of gauze moistened with epinephrine or lidocaine plus epinephrine should do the trick. Topical cocaine hydrochloride may also be available in some clinical settings. Don’t forget to reapply pressure after administration of the vasoconstrictor.

Master chemical cauterization

Cauterization with a silver nitrate stick is a highly effective form of treatment for anterior nose bleeds when more conservative methods have failed. When cauterizing the site of the bleed, remember:

  • Avoid cauterizing at random focusing only on the site of the bleeding
  • Do not cauterize both sides of the septum as this can lead to septal perforation
  • Start cauterization by rolling the silver nitrate stick on the tissues immediately surrounding the bleeding site then upon the source itself. Silver nitrate works best on a relatively bloodless surface.
  • Roll the silver nitrate stick over the area until a grey eschar forms, usually for about 5 to 10 seconds

Know your packing materials

If cautery fails or the exact site of bleeding cannot be identified, you may need to pack the affected nare. There are a few types of packing available on the market:

  • Merocel sponges-These can be placed quickly and easily but may not apply adequate pressure to the bleeding site. Apply antibiotic ointment to the sponge before placing to lubricate and facilitate healing.
  • RapidRhino-The RapidRhino consists of an inflatable balloon coated with a platelet aggregator to cause clotting at the bleeding site. Soak the RhinoRocket in a basin of water for 30 seconds before insertion to activate the lubricant. After inserting the device into the nare, inflate the device with air.

Generally, nasal packing is left in place for about 72 hours.

Effective after care

Recurrence of anterior epistaxis is common. Patients should be instructed to avoid NSAIDs for a few days following an episode of epistaxis. Vaseline or another moisturizing substance should be applied into the nares three times daily for a week following the episode to promote healing of the mucosa. Patients leaving the clinical setting with packing may need a prescription for analgesic medications. The need for prophylactic antibiotics to prevent toxic shock syndrome in patients with nasal packing is debated and has not been widely studied. Patients with posterior packing should be admitted to the hospital to monitor for airway obstruction. 

The following video clip gives a great visual summary of basic epistaxis treatment. 

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