Epistaxis Flashcards
(14 cards)
Definition
Anterior or posterior nose bleeds
Epidemiology
- Bimodal age distribution: children and older adults
- Dry, cold weather: especially winter
- Men aged < 50 are more likely to be hospitalised
Local factors Aetiology
- Idiopathic
- Digital trauma (nose picking)
- Other trauma (foreign bodies, nose-blowing, blunt facial trauma)
- Infection or inflammation (e.g. rhinitis)
- Tumurs e.g angiofibromas
- Septal deviation
- Illicit drug use e.g. cocaine is a vasoconstrictor and can cause oblitiratin of the septum with repeated used
Systemic factors aetiology
- Hypertension
- Anticoagulant medication
- NSAIDS
- Acquired coagulapathy (e.g. due to alcoholic liver disease)
- Hereditary predisposition to bleeding (haemophilia, von willerbrand disease, ITP)
- Other (Leaukaemia, Granulomatosis with polyangitis)
Pathophysiology
Anterior (90%) : Bleeding occurs from the front of the nose on the anterior nasal septum.
- SOURCE: Kiesselbach’s plexus which is an anastomosis of five arteries in the anterior nasal septum
Posterior (10%): Bleeding occurs from the posterior nasal cavity or nasopharynx. RISK of aspiration and airway compromise
- SOURCE: Sphenopalatine artery or terminal branches of maxillary artery
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Signs
- Bleeding from the nares
- Tachycardia (from anxiety, pain or shock)
- Dizziness and pre-syncope (if severe): blood visible in the oropharynx
- Abraded or atrophied nasal septum: enquire about cocaine
- Shock: pallor, hypotension, tachycardia if severe
Symptoms
- Feeling of blood in the throat
- Pain
- Dizziness and pre-syncope
- Anxiety
- ‘Pseudohaematemesis’ due to vomiting up of swallowed blood
Identifiying an anterior bleed
- Visible source of bleeding on examination
- Minor bleeding
- Bleeding initially unilateral
- History of digital trauma (picking nose)
- First aid measures successfully control the bleed
Identifying a posterior bleed
- No visible source of bleeding
- Bleeding down the back of the mouth and throat
- Bleeding initially bilateral
- Visible blood in the posterior pharynx
- ‘Pseudohaematemesis’
- Anterior nasal packing fails to control bleeding
Diagnosis
FIRST LINE: Examine the nose - use a nasal speculum, pen torch and head mirror with suction to facilitate visualisation
Consider:
- FBC and U+Es
- Crossmatch and group and save
- Coagulation studies
- Nasoendscopy or nasopharyngoscopy: visualise source of bleeding if tumour is suspected
Anterior bleeds treatment
FIRST LINE: First aid measures
SECOND LINE: Nasal cautery *only perform if a bleeding point is visible AND cautery can be tolerated
THIRD LINE: Anterior nasal packing for 24-48 hours if cautery is ineffective or CI - All patients require admission
Definitive surgical measures if above fails:
- Endoscopic ligation of the bleed
- Ligation through an external incision
- Interventional embolisation
Posterior nosebleeds
More likely to be severe begin fluid resuscitation early +/- blood products
FIRST LINE: First aid measures
SECOND LINE: Posterior nasal packing by ENT specialist
THIRD LINE: Emergency surgical management
If first aid measures are successful consider:
= Prescribing naseptin (topical antiseptic)
= Mupirocin nasal ointment if allergic to neomycin, peanut or soya
= Consider admission in children < 2 years if underlying cause suspected e.g. haemophilia or leaukaemia or sig co-moribitidy e.g. HTN
Discharge advice
- Do not lie flat for 24 hours
- Avoid nose-blowing for 1 week
- If sneeze keep mouth open
- Avoid alcohol, hot drinks and spicy food for 2 days
- Avoid strenuous exercise, heavy lifting or straining for 1 week
- Avoid dislodging scabs, including nose-picking and cleaning the inside of nose
