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Epistaxis: Treatment & Medication
Updated: Jul 16, 2009
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- Differential Diagnoses & Workup
- Treatment & Medication
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Treatment
Emergency Department Care
- As always, first address the patient's airway, breathing, and circulation (ABCs). Rarely, severe epistaxis may necessitate endotracheal intubation.
- Stable patients should be instructed to grasp and pinch their entire nose, maintaining continuous pressure for at least 10 minutes. Make sure to compress the soft nose tissues against the nasal septum. Pinching the hard, incompressible nasal bones will not aide hemorrhage control.
- Gowns, gloves, and protective eyewear should be worn. Adequate light is best provided by a headlamp with an adjustable narrow beam. Patients should be positioned comfortably in a seated position, holding a basin under their chin.
- Patients with significant hemorrhage should receive an IV line and crystalloid infusion, as well as continuous cardiac monitoring and pulse oximetry. Patients frequently present with an elevated blood pressure; however, a significant reduction can usually be obtained with analgesia and mild sedation alone. Specific antihypertensive therapy is rarely required and should be avoided in the setting of significant hemorrhage.
- Insert pledgets soaked with an anesthetic-vasoconstrictor solution into the nasal cavity to anesthetize and shrink nasal mucosa. Soak pledgets in 4% topical cocaine solution or a solution of 4% lidocaine and topical epinephrine (1:10,000) and place them into the nasal cavity. Allow them to remain in place for 10-15 minutes.
- If a bleeding point is easily identified, gentle chemical cautery may be performed after the application of adequate topical anesthesia. The tip of a silver nitrate stick is rolled over mucosa until a grey eschar forms. To avoid septal necrosis or perforation, only one side of the septum should be cauterized at a time. To be effective, cautery should be performed after bleeding is controlled. Thermal cautery using an electric cautery device is reserved for more aggressive bleeding under local or general anesthesia.1
- If attempts to control hemorrhage with pressure or cautery fail, the nose should be packed. Options include traditional nasal packing, a prefabricated nasal sponge, an epistaxis balloon, or absorbable materials.
- Traditional (Vaseline gauze) packing: This traditional method of anterior nasal packing has been supplanted by readily available and more easily placed tampons and balloons. It is commonly performed incorrectly, using an insufficient amount of packing placed primarily in the anterior naris. Placed in this way, the gauze serves as a plug rather than as a hemostatic pack. Physicians inexperienced in proper placement of a gauze pack should use a nasal tampon or balloon. The proper technique for placement of a gauze pack is as follows:
- Grasp the gauze ribbon, about 6 inches from its end, with bayonet forceps. Place it in the nasal cavity as far back as possible, ensuring that the free end protrudes from the nose. On the first pass, the gauze is pressed onto the floor of nasopharynx with closed bayonets.
- Next, grasp the ribbon about 4-5 inches from the nasal alae and reposition the nasal speculum so that the lower blade holds the ribbon against lower border of nasal alae. Bring a second strip into the nose and press downward.
- Continue this process, layering the gauze from inferior to superior until the naris is completely packed. Both ends of ribbon must protrude from the naris and should be secured with tape. If this does not stop the bleeding, consider bilateral nasal packing.
- Compressed sponge (Merocel): Trim the sponge to fit snugly through the naris. Moisten the tip with surgical lubricant or topical antibiotic ointment. Firmly grasp the length of the sponge with bayonet forceps, spread the naris vertically with a nasal speculum, and advance the sponge along the floor of the nasal cavity. Once wet with blood or a small amount of saline, the sponge expands to fill the nasal cavity and tamponade bleeding. See Media files 1 and 2.
- Traditional (Vaseline gauze) packing: This traditional method of anterior nasal packing has been supplanted by readily available and more easily placed tampons and balloons. It is commonly performed incorrectly, using an insufficient amount of packing placed primarily in the anterior naris. Placed in this way, the gauze serves as a plug rather than as a hemostatic pack. Physicians inexperienced in proper placement of a gauze pack should use a nasal tampon or balloon. The proper technique for placement of a gauze pack is as follows:
Compressed sponge - Merocel.
Merocel placed in left nostril for anterior packing.
- Anterior epistaxis balloons (Rapid Rhino): Anterior epistaxis balloons are available in different lengths. A carboxycellulose outer layer promotes platelet aggregation. The balloons are as efficacious as nasal tampons with superior ease and patient comfort on insertion and removal. To insert, soak the knit outer layer of the balloon with water, insert along the floor of the nasal cavity, and inflate slowly with air until the bleeding stops. See Media files 3 and 4.
Rapid Rhino - 5.5 cm for anterior nasal packing.
Rapid Rhino bilateral - 7.5 cm for anterior/posterior nasal packing.
- Absorbable materials such as oxidized cellulose (Surgicel), gelatin foam (Gelfoam), and gelatin and thrombin combination (FloSeal) are suitable alternatives to nasal packing for anterior bleeds. They directly tamponade bleeding sites, increase clot formation, and protect the nasal mucosa from desiccation or further trauma. They are easy to use, comfortable, and conform to the irregularity of the nasal contours.2,4
- Posterior epistaxis balloons: Posterior epistaxis balloons generally have separate anterior and posterior balloons.
- After passing the posterior balloon through the naris and into the posterior nasal cavity, inflate it with 4-5 mL of sterile water and gently pull it forward to fit snugly in the posterior choana. After bleeding into the posterior pharynx has been controlled, fill the anterior balloon with sterile water until the bleeding completely stops.
- Avoid overinflation because pressure necrosis or damage to the septum may result. Record the amount of fluid placed in each balloon.
- If a Foley catheter is used, place a 12-16F catheter with a 30-mL balloon into the nose along the floor of the nasopharynx, until the tip is visible in the posterior pharynx.
- Slowly inflate the balloon with 15 mL of sterile water, pull it anteriorly until it firmly sets against the posterior choanae, and secure it in place with an umbilical clamp. Use a buttress clamp with cotton gauze to avoid pressure necrosis on the nasal alae or columella. Finally, an anterior nasal pack should be placed.
- For additional information, see Nasal Pack, Anterior Epistaxis and Nasal Pack, Posterior Epistaxis.
Consultations
Epistaxis that requires posterior packing should be managed in cooperation with an ear, nose, and throat (ENT) specialist. Because of multiple possible complications, admission is required, usually in a monitored setting.
Consultation with a hematologist is indicated for patients with bleeding dyscrasias or coagulopathies.
Medication
Patients discharged from the hospital with anterior packing should receive follow-up care with an ENT specialist within 48-72 h. Nasal packing prevents drainage of sinuses. Consider placing patients on a broad-spectrum antibiotic to cover all likely pathogens in the context of the clinical setting.
Oral analgesics should be prescribed to assure quality patient care.
Antibiotics
Consider giving patients a penicillin or first-generation cephalosporin.
Amoxicillin (Biomox, Trimox)
Treats infections caused by susceptible organisms and used as prophylaxis in minor procedures.
Adult
250-500 mg PO q8h; not to exceed 3 g/d
Pediatric
20-50 mg/kg/d PO q8h
Reduces the efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Cephalexin (Keflex)
First-generation cephalosporin, which is primarily active against skin flora. Used for skin structure coverage and as prophylaxis in minor procedures.
Adult
250-1000 mg PO q6h; not to exceed 4 g/d
Pediatric
25-50 mg/kg/d PO q6h; not to exceed 3 g/d
Coadministration with aminoglycosides increases nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Most analgesics have sedating properties, which are beneficial for patients who have painful skin lesions. Avoid NSAIDs and aspirin.
Acetaminophen (Tylenol, Aspirin Free Anacin, Feverall)
DOC for treating pain in documented hypersensitivity to aspirin, upper GI disease, or concurrent administration of oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg PO tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum dose
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
For the relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn for pain
Pediatric
<12 years: Based on acetaminophen dose of 10-15 g/kg/dose PO q4-6h prn; not to exceed 10 mg/dose of hydrocodone bitartrate or 2.6 g/d of acetaminophen
>12 years: Based on acetaminophen dose of 750 mg PO q4h; not to exceed 5 doses q24h
Phenothiazines may decrease the analgesic effects; toxicity increases with coadministration of CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tabs contain metabisulfite, which may cause allergic reactions
More on Epistaxis |
| Overview: Epistaxis |
| Differential Diagnoses & Workup: Epistaxis |
 Treatment & Medication: Epistaxis |
| Follow-up: Epistaxis |
| Multimedia: Epistaxis |
| References |
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References
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Further Reading
Keywords
epistaxis, nose bleed, nasal hemorrhage, nosebleed, bloody nose, nasal packing, nosebleed treatment, nosebleed causes
