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To manage epistaxis, sequentially:
- Assess the person’s airway, breathing, pulse, and blood pressure
- Advise the patient to pinch the cartilaginous part of the nose firmly and hold it for 10 – 15 minutes without releasing the pressure, while leaning forwards (leaning forward decreases blood flow through the nasopharynx, allows spitting out of blood, and minimises swallowing blood that drains into the pharynx)
- Examine the nasal passages and try to identify a bleeding point
- If a bleeding point is identified, nasal cautery can be attempted. Ask the person to blow their nose to clear any clots and allow local anaesthetic to be applied. Use a topical local anaesthetic spray, preferably with a vasoconstrictor (such as lidocaine with phenylephrine [Co-phenylcaine®]), prior to cauterising the area. Wait 3–4 minutes for the full effect. The vasoconstrictor may stop the bleeding, but once the effects have worn off, the bleeding may start again. Lightly apply the silver nitrate stick to the bleeding point for 3–10 seconds until a grey-white colour develops. Only cauterise one side of the septum to avoid nasal septal perforation. After cautery, apply a topical antiseptic preparation to the area (use Naseptin® (chlorhexidine and neomycin) cream first line, applied to the nostrils four times daily for 10 days)
- If nasal cautery is unsuccessful or a bleeding point cannot be identified, nasal packing can be performed. Prior to packing, anaesthetise the nasal cavity with topical local anaesthetic spray, preferably one with a vasoconstrictor (for example lidocaine with phenylephrine [Co-phenylcaine®]), if this has not already been done. Wait 3–4 minutes for the full effect. Packing may be achieved with nasal tampons, inflatable packs (e.g. Rapid-Rhino®), or ribbon gauze impregnated with Vaseline® or bismuth-iodoform paraffin paste.
Check the oropharynx for signs of bleeding from the back of the nose. If bleeding is seen, consider packing the other nostril to increase pressure on the bleeding vessel. Patients who require packing will need admitting under ENT.
- If bleeding from the posterior area of the nose is suspected (bleeding is profuse, from both nostrils, and the bleeding site cannot be identified on speculum examination), refer urgently to ENT. Posterior packing can be attempted with a Foley catheter or a nasal tampon with a posterior balloon.
- Laboratory investigations are usually unnecessary; a FBC should be considered if bleeding has been heavy or recurrent, clotting should be requested only if a clotting disorder is suspected/patient is taking anticoagulants.
Further treatments for acute epistaxis include:
- Resuscitation — this may include transfusion to replace blood volume and provide coagulation factors
- Formal packing (may be under general anaesthetic)
- Endoscopic assessment and electrocautery
- Examination under anaesthesia, and surgical intervention (such as diathermy, septal surgery, arterial ligation, and laser treatment)
- Radiological arterial embolization Intravenous or oral tranexamic acid
If bleeding stops with initial simple measures, observe for a further 15 minutes, and then consider discharge with self-care advice. Advise that for 24 hours after bleeding, where practical, the person should avoid activities which may increase the risk of rebleeding. These include:
- Blowing or picking the nose
- Heavy lifting
- Strenuous exercise
- Lying flat
- Drinking alcohol or hot drinks
The patient should be advised to return if bleeding restarts.