Epistaxis

Epistaxis (nose bleeds) is split into anterior and posterior bleeds, whereby the former often has a visible source of bleeding and usually occurs due to an insult to the network of capillaries that form Kiesselbach's plexus. Posterior haemorrhages, on the other hand, tend to be more profuse and originate from deeper structures. They occur more frequently in older patients and confer a higher risk of aspiration and airway compromise.

Causes

• most cases of epistaxis tend to be benign and self-limiting. Exacerbation factors include:
  • nose picking
  • nose blowing
• trauma to the nose
• insertion of foreign bodies
• bleeding disorders
  • immune thrombocytopenia
  • Waldenstrom's macroglobulinaemia
• juvenile angiofibroma
  • benign tumour that is highly vascularised
  • seen in adolescent males
• cocaine use
  • the nasal septum may look abraded or atrophied, inquire about drug use. This is because inhaled cocaine
  • cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.
• hereditary haemorrhagic telangiectasia
• granulomatosis with polyangiitis

Management

If the patient is haemodynamically stable, bleeding can be controlled with first aid measures. This involves:

• Asking the patient to sit with their torso forward and their mouth open
  • avoid lying down unless they feel faint
  • his decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth
  • it also reduces the risk of aspirating blood
• Pinch the cartilaginous (soft) area of the nose firmly
  • this should be done for at least 20 minutes
  • also ask the patient to breathe through their mouth.

If first aid measures are successful

• consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis
  • Mupirocin is a viable alternative
• admission and follow up care may be considered in patients under if
  • a comorbidity (e.g. coronary artery disease, or severe hypertension) is present, an underlying cause is suspected
  • they are aged under 2 years (as underlying causes such as haemophilia or leukaemia are more likely in this age group)
• self-care advice involves reducing the risk of re-bleeding
  • patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks should be avoided

If bleeding does not stop after 10-15 minutes of continuous pressure on the nose consider cautery or packing