eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Epistaxis: Follow-up

Author: Ola Bamimore, MD, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center
Coauthor(s): Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Contributor Information and Disclosures

Updated: Jul 16, 2009

Follow-up

Further Inpatient Care

  • Admit patients with posterior packing. Elderly patients or patients with cardiac disorders or chronic obstructive pulmonary disease (COPD) should receive supplemental oxygen and be admitted to a monitored setting.
  • Significant or uncontrolled bleeding from a posterior site may require operative management; this occurs in about 30% of cases. Interventional radiology embolization of involved arteries and surgical ligation of vessels are possible options in such instances.4

Further Outpatient Care

  • Patients discharged with anterior packing should receive follow-up care with an ENT specialist within 48-72 hours. Nasal packing increases the risk of sinusitis or toxic shock syndrome.
  • Patients discharged with nasal packing should be prescribed a penicillin or first-generation cephalosporin. Oral analgesics should also be prescribed.
  • Advise patients to avoid aspirin, aspirin-containing products, and NSAIDs.
  • Patients who take warfarin may generally continue their current regimen unchanged. Temporary discontinuation of warfarin or active reversal of coagulopathy is indicated only in cases of uncontrolled hemorrhage and supratherapeutic INR.
  • Give patients specific written follow-up instructions.

Complications

  • Sinusitis
  • Septal hematoma/perforation
  • External nasal deformity
  • Mucosal pressure necrosis
  • Vasovagal episode
  • Balloon migration
  • Aspiration

Prognosis

  • With proper treatment, prognosis is excellent.

Patient Education

  • For rebleeding or future nosebleeds, patients should be instructed to firmly pinch their entire nose for 10-15 minutes. Ice packs do not help.5
  • Encourage nasal hydration with topical gels, lotions, or ointments to moisturize mucosa and promote healing of friable areas. Humidifiers or vaporizers in bedrooms may increase ambient humidity.3,2
  • For excellent patient education resources, visit eMedicine's Ears, Nose, and Throat Center. Also, see eMedicine's patient education article Nosebleeds.

Miscellaneous

Medicolegal Pitfalls

  • Posterior nasal packing is particularly uncomfortable for the patient and promotes hypoxia and hypoventilation. Failure to admit and appropriately monitor all patients who require posterior packing may result in significant mortality.
  • Attempts at nasal packing may result in significant slowing but not cessation of hemorrhage. Failure to completely control hemorrhage is an absolute indication for consultation with an ENT specialist in the ED.
  • Nasal packing can lead to serious infection. Patients discharged with anterior nasal packs should be started on oral antibiotics.
  • Tumors or other serious pathology are infrequent causes of epistaxis. However, all patients who present with epistaxis should have follow-up care arranged with an ENT specialist for a complete nasopharyngeal examination. Recurrent unilateral epistaxis should particularly raise concern for neoplasm.1
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Jeffrey A Evans, MD, and Todd Rothenhaus, MD, to the development and writing of this article.



More on Epistaxis

Overview: Epistaxis
Differential Diagnoses & Workup: Epistaxis
Treatment & Medication: Epistaxis
Follow-up: Epistaxis
Multimedia: Epistaxis
References
[ CLOSE WINDOW ]

References

  1. Cummings CW. Epistaxis. In: Cummings: Otolaryngology: Head and Neck Surgery. 4th ed. Philadelphia, Pa: Elsevier, Mosby; 2005:Chap 40.

  2. Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. Jun 2008;41(3):525-36, viii. [Medline].

  3. Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. Feb 19 2009;360(8):784-9. [Medline].

  4. Douglas R, Wormald PJ. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg. Jun 2007;15(3):180-3. [Medline].

  5. Teymoortash A, Sesterhenn A, Kress R, et al. Efficacy of ice packs in the management of epistaxis. Clin Otolaryngol Allied Sci. Dec 2003;28(6):545-7. [Medline].

  6. Badran K, Malik TH, Belloso A, Timms MS. Randomized controlled trial comparing Merocel and RapidRhino packing in the management of anterior epistaxis. Clin Otolaryngol. Aug 2005;30(4):333-7. [Medline].

  7. Cassisi NJ, Biller HF, Ogura JH. Changes in arterial oxygen tension and pulmonary mechanics with the use of posterior packing in epistaxis: a preliminary report. Laryngoscope. Aug 1971;81(8):1261-6. [Medline].

  8. Choudhury N, Sharp HR, Mir N, Salama NY. Epistaxis and oral anticoagulant therapy. Rhinology. Jun 2004;42(2):92-7. [Medline].

  9. Cook PR, Renner G, Williams F. A comparison of nasal balloons and posterior gauze packs for posterior epistaxis. Ear Nose Throat J. Sep 1985;64(9):446-9. [Medline].

  10. Corbridge RJ, Djazaeri B, Hellier WP, Hadley J. A prospective randomized controlled trial comparing the use of merocel nasal tampons and BIPP in the control of acute epistaxis. Clin Otolaryngol Allied Sci. Aug 1995;20(4):305-7. [Medline].

  11. Fairbanks DN. Complications of nasal packing. Otolaryngol Head Neck Surg. Mar 1986;94(3):412-5. [Medline].

  12. Fuchs FD, Moreira LB, Pires CP, et al. Absence of association between hypertension and epistaxis: a population-based study. Blood Press. 2003;12(3):145-8. [Medline].

  13. Guarisco JL, Graham HD 3d. Epistaxis in children: causes, diagnosis, and treatment. Ear Nose Throat J. Jul 1989;68(7):522, 528-30, 532 passim. [Medline].

  14. Hashmi SM, Gopaul SR, Prinsley PR, Sansom JR. Swallowed nasal pack: a rare but serious complication of the management of epistaxis. J Laryngol Otol. May 2004;118(5):372-3. [Medline].

  15. Herkner H, Havel C, Mullner M. Active epistaxis at ED presentation is associated with arterial hypertension. Am J Emerg Med. Mar 2002;20(2):92-5. [Medline].

  16. Karras DJ, Ufberg JW, Harrigan RA, et al. Lack of relationship between hypertension-associated symptoms and blood pressure in hypertensive ED patients. Am J Emerg Med. Mar 2005;23(2):106-10. [Medline].

  17. Keen MS, Moran WJ. Control of epistaxis in the multiple trauma patient. Laryngoscope. Jul 1985;95(7 Pt 1):874-5. [Medline].

  18. Larsen K, Juul A. Arterial blood gases and pneumatic nasal packing in epistaxis. Laryngoscope. May 1982;92(5):586-8. [Medline].

  19. Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. May 2005;81(955):309-14. [Medline].

  20. Singer AJ, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Ann Emerg Med. Feb 2005;45(2):134-9. [Medline].

  21. Van Wyk FC, Massey S, Worley G, Brady S. Do all epistaxis patients with a nasal pack need admission? A retrospective study of 116 patients managed in accident and emergency according to a peer reviewed protocol. J Laryngol Otol. Mar 2007;121(3):222-7. [Medline].

  22. Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications. Ann Emerg Med. May 1995;25(5):592-6. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

epistaxis, nose bleed, nasal hemorrhage, nosebleed, bloody nose, nasal packing, nosebleed treatment, nosebleed causes

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Ola Bamimore, MD, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center
Ola Bamimore, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School
Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.