Epistaxis (Nose bleeding)

Notes
  • This is defined as bleeding from the nose
  • At least 90% of episodes of epistaxis are from a plexus of veins in the Little’s area.
  • Epistaxis can either be anterior epistaxis, which is more common and posterior epistaxis that less common but more serious condition
  • Occasionally in epistaxis, blood can come up the nasolacrimal duct and out from the eye.
  • Sometimes, especially in posterior epistaxis, fresh and clotted blood can flow down into the stomach and cause nausea and vomiting
  • Most cases of epistaxis are benign, self-limiting, and spontaneous, though some can be recurrent
  • Statistics: Epistaxis is generally not a fatal condition, in the USA its mortality is 4 in 2.4 million; approximately 60% of the global population have a nosebleed at some point in their life

## Causes of epistaxis:

  • Trauma
  • Picking and /or blowing of the nose
  • Nasal infections
  • Hypertension
  • Acute fevers
  • Blood clotting disorders
  • Renal diseases with uremia
  • Foreign body in the nose
  • Nasal and paranasal neoplasms
  • Dry cold conditions
  • Von Willebrand's disease
  • Vitamin C and vitamin K deficiency
  • Liver cirrhosis that causes deficiency of factor II, VII, IX,& X
  • Preexisting atherosclerotic vessels
Symptoms
  • Nose bleeding
Diagnosis
  • Clinical evaluation
  • Tests related to the suspected underlying causes
Differential
  • Disseminated Intravascular Coagulation
  • Hemophilia
  • Drug or chemical toxicity e.g. warfarin, salicylate, rodenticide and plant coumarins
  • Endometritis of the nose
  • Rhinitis
  • Underlying systemic disease such as hypertension, infections, and Renal diseases with uremia among others
  • Foreign body in the nose
Prevention
  • Treatment of underlying disease(s)
  • Topical antibiotic prophylaxis of recurrent epistaxis
Management
  • Sit the patient up to avoid aspiration of blood
  • Pinch the nose for 10-20 minutes
  • Apply ice or cold pack on the bridge of the nose

##Packing the nose with paraffin pack:

  • Remove clots with suction catheter
  • Apply xylocaine nasal spray AVOIDING the use of adrenaline

(NB: Some literature still advocate for the use of topical adrenaline in treatment of epistaxis)

  • Prepare a length of ribbon gauze impregnated with petrolatum jelly
  • Use bayonet forceps or Tiley’s forceps and a nasal speculum to place the gauze in a layered, accordion fashion, packing it from anterior to posterior (from the floor to the roof).
  • Remove the pack after 24 - 48hrs
  • Toxic shock syndrome can occur in rare cases.

##Cauterization of the nose:

  • This is recommended after a specific bleeding point is identified and the bleeding has stopped
  • It is done under local anesthesia
  • The tip of a silver nitrate stick is rolled over nasal mucosa until a gray eschar forms.
  • Cauterize only one side of the septum at a time to prevent septal necrosis or perforation
  • Thermal cauterization (under local or general anesthesia) is only used for more serious bleeding.

## For patients with significant hemorrhage:

  • Set the IV line and administer crystalloid infusion while monitoring functions and pulse oximetry

##Other forms of management

  • Arterial ligation (in treatment of resistant epistaxis)
  • Embolization (in treatment of resistant epistaxis)

##Treatment of underlying causes

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