Managing Nosebleeds

Junior doctors are likely to see epistaxis in the acute setting, write Samuel Cartwright and colleagues Epistaxes (nosebleeds) are a fairly common presentation in the emergency department, and a working knowledge of the principles of management is important for junior doctors. Most cases resolve spontaneously, but patients who present at emergency departments need reassurance and prompt structured care. We also consider more specialist care. Most epistaxis is idiopathic, but there are recognised causes (box). In nine cases out of ten epistaxes occur in the Kiesselbachs plexus, at the anterior portion of the septum known as Littles area (fig 1). Littles area is an anastomotic arterial plexus that involves all five arteries that supply the septumthe anterior ethmoidal and posterior ethmoidal arteries of the internal carotid artery and the greater palantine, sphenopalatine, and superior labial arteries of the external carotid artery.

Fig 1 Vascular anatomy of nasal septal blood supply Main causes of epistaxisw1 Local

Idiopathic Infection Traumasuch as nose picking, facial injury Neoplasia Foreign body

General

Drugssuch as anticoagulants Blood diseasessuch as leukaemia 1

Hereditary haemorrhagic telangiectasia Hypertension may exacerbate bleeding

Scenario 1A 4 year old boy presents to his general practitioner with his anxious mother after he had a nosebleed that morning. Trauma from nose picking is a common cause of bleeding in this age group, but in many children no obvious cause is found. A detailed history may show a tendency for prolonged bleeding and may raise suspicion of a clotting disorder. In any scenario it is worth asking specifically which nostril began bleeding first. Bilateral bleeding is uncommon. Initial first aid Basic first aid is Trotters methodmanual compression of the lower nostrils; sitting upright to reduce blood pressure; and leaning forward to stop swallowing (fig 2). Apply pressure continuously for up to 10 minutes. In this time assess the patient for signs of shock and resuscitate appropriately. Applying pressure higher up, to the bony bridge of the nose, is ineffective because no pressure is applied to the septum.

Fig 2 Trotters method, compressing the lower nostrils and applying pressure to the septum Management If simple pressure works it is likely that the bleeding point is on the nasal septum or in the anterior nasal cavity. Look for the offending vessel, and cauterise it to prevent further bleeding.w2 You should wear gloves, a gown, and eye protection. The patient should clear their nose by blowing it, with caution. Examine the nose using a headlight if available, which leaves both hands free to use instruments and apply suction. A Thudicums speculum is the instrument of choice (fig 3). Ask an ear, nose, and throat surgeon how to hold one because there is a knack. Other nasal speculums existfor example, Vienna, HartmannHalle, and Cottle speculums. A good view of the septum is often obtained by raising the nasal tip with the thumb (fig 4).

Fig 3 Thudicums speculum in situ

Fig 4 Raising the nasal tip with the thumb In scenario 1, indicators of shock are a good starting point for managing the patient, but the extent to which they affect treatment varies. Bleeding in children is usually less severe but may be persistent and troublesome. Treatment with petroleum jelly, chlorhexidine and neomycin cream, or silver cautery may be used. Remove stubborn clots by suction. A topical anaesthetic combined with a vasoconstrictor makes inspection of the nose easier. Examples are lidocaine with adrenaline; co-phenylcaine; or cocaine solution, which is used less often because of dysrhythmogenic properties. Apply these to the nose as spray or on a cotton wool pledget placed in the nose with nasal dressing forceps.w3 Leave to work for 10 minutes or so to encourage as much vasoconstriction as possible. Scenario 2An elderly man presents with recurrent nose bleeds in the last four weeks. The bleeds are not torrential, but Trotters method is not sufficient to resolve the problem. 3

In older patients the nasal vessels may not constrict as readily because of associated vascular disease. In many cases the offending vessel will be seen clearly on Littles area. If Littles area is not bleeding, there is often a telltale volcano on the septuma tiny clot that if gently brushed begins to bleed. If this is the case, the vessel can usually be controlled by cautery. Cautery There are two main methods of cautery. Chemical cautery is a simple procedure in which a silver nitrate stick reacts with the mucosal lining to produce local chemical damage. For maximal effect apply the stick in decreasing concentric circles around the bleeding vessel. Electrocautery and diathermy need more specialist equipment and are indicated if silver nitrate does not control the bleeding. Electrocautery is the application of an instrument heated by direct high frequency electrical current. Diathermy also uses high frequency current, but the current passes through the patient. The instrument forms one electrode, the other is a moistened pad applied to the patients body. At this stage involve an ear, nose, and throat surgeon to show you how it is done. These measures work for most simple epistaxes. Occasionally, however, bleeding continues from a source somewhere out of view in the back of the nose. At this stage you and the patient will be pretty fed up, so now is the time to formally pack the nose with a nasal tampon and refer to the ear, nose, and throat team for further assessment. Scenario 3A 75 year old woman presents with epistaxis. She has well controlled atrial fibrillation and takes warfarin. The bleeding is not controlled by pressure, and the bleeding point cannot be seen on anterior rhinoscopy. In this case anticoagulation contributes to continued haemorrhage. Warfarin is commonly used in atrial fibrillation to prevent sequelae of stroke, pulmonary embolism, and so on. The international normalised ratio and drugs should be reviewed because it is common for patients taking warfarin to be outside the therapeutic range because of drug interactions or confusion about the correct dose of anticoagulant. As well as further measures to control the bleeding, these patients should be resuscitated and blood taken for full blood counts, clotting screen, and a group and save. Take greater caution for elderly patients with comorbidities. Assess the patient taking into account the potential contraindications of treatment and the effects of and effects on pre-existing conditions. This is true in all disciplines of medicine. Nasal packing The nose can be packed with a variety of materials,w4 but they all try to provide a tamponade effect at the bleeding point. Before trying to pack a nose, remember that the floor of the nose goes straight back, not up. Awareness of this simple fact will make putting the pack in much easier.

Explain to the patient what you are about to do. Tell him or her that it will be uncomfortable but only for a few seconds. Clean out the nasal cavity with suction and by asking the patient to blow the nose. Lift the tip of the nose with the thumb. Push the pack in along the floor of the nose until it is fully inserted (fig 5). Some packings need gentle inflation with 5 ml saline or water. Occasionally putting a pack in can be difficult because of anatomical constraints in the nose for example, a deviated nasal septum. If this is the case ask for help from ear, nose, and throat department. Pushing the pack up towards the roof of the nose is uncomfortable for the patient. The lack of room means that you wont be able to get the pack all the way in. In the United Kingdom standard practice is to admit the patient to the ward for overnight care after nasal packing. This is usually the responsibility of the ear, nose, and throat team.w5

Fig 5 The correct angle of insertion of the nasal pack (90) Scenario 4A 45 year old man presents to the emergency department with heavy epistaxis. On examination the patient has small red spots on his face and torso. On questioning he has had recurrent nosebleeds all his life and his father died of an upper gastrointestinal bleed aged 55. The spots on the mans body and his family history are evidence of hereditary haemorrhagic telangiectasia. This is an autosomal dominant disorder that manifests as telagiectases of the skin and mucous membranes and arteriovenous malformations. Larger telangiectases can affect the nasopharynx, central nervous system, lung, liver, spleen, and urinary and gastrointestinal tracts. Epistaxis is the most common presentation. Carry out normal procedures to stop bleeding, but inform the ear, nose, and throat team early for ongoing care. Surgery If a patient continues to bleed after packing, surgery is indicated.w6 Methods such as septal surgery and arterial ligation may be used. Septal surgery may be necessary if a large septal spur is present, preventing visualisation of the nasal

cavity and packing. Arterial ligation may be necessary, particularly for posterior epistaxis. The most commonly ligated vessel is the sphenopalatine artery, which supplies blood to much of the posterior two thirds of the nose. The artery can be located endoscopically by raising a flap of mucosa off the lateral nasal wall beneath the middle turbinate. Once located, the vessel can be diathermied or clipped. For more anterior bleeds the anterior ethmoid artery can be approached externally through a small incision in the medial wall of the orbit. Embolisation Rarely a patient may not respond to surgical attempts to control bleeding or may not be fit enough for a general anaesthetic. Embolisation entails the introduction of embolic material to reduce or completely obstruct blood flow. Under x ray screening, a cannula is inserted into the artery suppling the affected area, and occluding material is injected, such as microspheres, metallic coils, or polyvinyl alcohol foam. In this situation it is sometimes possible to enlist the help of a skilled interventional radiologist to embolise the offending vessel. However, this is highly specialised care and often requires transfer to a tertiary centre. Summary As for the management of many common conditions consensus on exact protocol may vary depending on a doctors experience and beliefs. However, this article is intended to provide a basis from which junior doctors can work (fig 6).

Fig 6 Management algorithm

http://archive.student.bmj.com/issues/08/05/education/212.php Samuel J Cartwright foundation year one doctor Broomfield Hospital, Chelmsford sjcartwright@doctors.org.uk Jonathan J Morris foundation year one doctor Swansea Hospital, Swansea Darren Pinder consultant in ear, nose, and throat surgery Footscray Hospital, Melbourne, Australia Student BMJ 2008;16:212-214 | 17