CCFP Topic: Epistaxis

Establish how urgent you need to manage the nosebleed. Assess ABCs. The airway can be compromised and you may need to protect it. They can also have a significant amount of blood loss to the point of instability. Sit them up and forward. Assess their vital signs. Establish IV access. Think about whether they need IV fluids or blood. 

Also ask about symptoms that can be caused by blood loss, like ​​dyspnea, sweating, chest pain/pressure, left arm pain, jaw pain, and syncope.

This is actually quite important. The guideline mentions the Parental Stress Index Short Form test of stress that showed one third of pediatric patients with epistaxis and 44% of their parents had high stress scores. 

Enter the room cool and collected and explain that we have many tricks up our sleeves to manage this issue, including ways to prevent them from occurring in the future.

In your history, establish which side, duration and estimated quantity of blood. Is the nosebleed in the context of a change in weather, illness, or particular trauma to the nose?

Inquire about foreign bodies. This is especially important in children, when you may have to fish the foreign body out. Unless a patient offers it up to use, it is probably not worth asking them if they picked their nose. There is a high chance that they did and likely they don’t want to admit to that. Plus, it doesn’t affect management.

Hemoptysis and/or hematemesis may be suggestive of posterior epistaxis.

Inquire about previous events of epistaxis and the context around there. Or perhaps they have bleeding elsewhere, for example, gum or Gi bleeding and bruising. These features may suggest a bleeding disorder.

On past medical history, ask about whether they have concurrent disorders of HTN, anemia, cardiopulmonary dz, bleeding disorders, liver or kidney dz, HIV, recent nasal or facial trauma, prior nasal or sinus surgery, nasal malignancies, or if they have been exposed to irritants like cigarette smoking.

If they have had previous events of epistaxis, have they required hospitalization or transfusion? These may influence treatment.

What medications do they take? Pay particular attention to:

• Intranasal medication, especially intranasal steroid sprays or intranasal drug use, such as cocaine.
  • Anticoagulation or antiplatelet agents
  • Are they on home oxygen or a CPAP? Hospitalized patients may be using nasal cannulas, predisposing them to nosebleeds.

Relevant family history includes

• Family history of coagulopathies
  • Family history of significant nose bleeds

Rare things to think of in pediatric patients:

• HHT (hereditary hemorrhagic telangiectasia)
  • For adolescent males, think of juvenile nasopharyngeal angiofibroma, which is a vascular benign tumour.
  • Glanzmann thrombasthenia – very rare coagulopathy from a platelet issue.

Other neoplasms are possible, such as squamous cell carcinoma, melanoma, and adenoid cystic carcinoma.

On exam, Take note of their blood pressure. Hypertension is associated, but not causative. It is more likely that the elevated blood pressure is secondary to pain or anxiety. Reducing BP has not shown to help control the bleed. Treat the anxiety and pain if necessary and consider remeasuring after controlling the bleed.

It is also worth noting any other features on your exam that would factor into your care such as other sites of bleeding, bruising, stigmata of liver disease etc.

The reason they target anterior bleeds here is because 90% of epistaxis cases are anterior bleeds at Little’s area, aka Kiesselbach plexus, aka where the superior labial artery, the anterior ethmoidal and the terminal branch of the sphenopalatine artery all meet on the anterior septum. Initial control of the bleeding is critical to appropriately view the area.

One of the first steps is to pinch the lower ⅓ of the nose for at least 5 minutes, 10 minutes or longer is likely to be better. The pediatric nosebleed attachment in this resource says at least 20 minutes. Tintinalli’s says 10-15 minutes undisturbed. Make sure it is firm and undisturbed!

You can consider using nasal clamps or having one of their support people help. These instructions are usually given at triage and often resolve the nosebleed in the waiting room.

There is a common misconception that people need to pinch the base of their nose and lean back. This is wrong! Pinch  the nasal ala against the septum, not the bone. Do this sitting up and leaning forward slightly, which helps prevent blood from being swallowed.

Now, hopefully when you see the patient, the bleeding has either stopped or has been completely controlled. It is a good idea to gown up anyways because these situations can get messy. Don’t forget eye protection! Before you get started, have them blow out any clots so you can see what you are doing and apply medications to the right spot.

If the bleeding has already stopped, great! You’re done. If not, we must visualize, anesthetize, cauterize, and pack the bleed.

Next, vasoconstrict and anesthetize to help you visualize. Anesthetize with cotton pledget soaked 1:1 with 4% lidocaine and oxymetazoline, a vasoconstricting decongestant that shrinks blood vessels in the nasal passage. Stick these in both nares, even if blood is only coming out of one. You can also use lidocaine with epi, though oxymetazoline seems to be more effective. Remove after about 10 minutes to visualize the bleed.

Having the patient suck on ice cubes or a popsicle can be a good idea as this can reduce blood flow to the potential bleeding sites through vasoconstriction. This may also help win over your pediatric patients.

Next step is to try to visualize the area of the anterior septum using a nasal speculum. Get geared up with a head lamp, face and eye protection and even a gown. You want to be protected if the patient sneezes, which is highly likely.

Nasal speculum technique. Sagittal plane (ie. opening it vertically). A common mistake is to open it horizontally.

Need to be able to visualize the site of the bleed. If you can’t see it, you need the next steps of your treatment to help determine whether you are missing a posterior bleed.

If two attempts at pressure have failed, try silver nitrate chemical cautery. Make sure it is anesthetized with 1:1 solution of oxymetazoline 0.05% and 4% lidocaine on a pledget before cauterizing because this is painful. Silver nitrate causes sneezing, so remember PPE. Do we sound like a broken record? Don’t cauterize both sides as this can cause septal necrosis and

perforation. Make sure it is a relatively blood free field, otherwise silver nitrate won’t work. Lightly touch the silver nitrate to the adjacent area for a second or two at each site  for 5-10 seconds, and no more than 15. Apply polysporin after.

• If the patient rebleeds shortly after this application, like days after, can’t do silver nitrate again. Need to wait 4-6 weeks between applications.

• Other things that can be tried:
  • Absorbable foams and gels on visualized bleeding site, especially in coagulopathic patients.These don’t need to be removed which is great.
  • txa: 200 mg atomized, cotton pledget with 500 mg on it, or 500 mg with 5 cc NS atomized. The evidence for TXA in epistaxis isn’t great, as reinforced by the NoPAC trial in June 2021. In adult patients with persistent atraumatic epistaxis after local pressure/ice to the bridge of the nose for 10 minutes AND topical vasoconstrictor for 10 minutes. The use of topical TXA (200mg) for 10 minutes with pressure vs. sterile water for 10 minutes with pressure showed no statistical difference in the number of patients who required anterior packing.

If these have all failed, or some are unavailable, we move on to nasal packing. Anterior epistaxis balloons, like Rapid Rhino, are easy to insert. I’ve mostly seen these used as opposed to other forms of packing, such as gauze strips or foams. Soak it in water or TXA for about 30 seconds and then insert it with slow, but fairly firm motion.

Is quite uncomfortable for the patient, so warn them beforehand. iInflate these with air and not water, because these can burst and water can be aspirated.

You may need a bilateral anterior pack to increase the tamponade. If this isn’t working, you may have a posterior bleed.

You may need to consider abx such as amoxi clav to reduce TSS or sinusitis. However, most patients don’t need these. If they are expected to have packing in for more than 4 days or are immunocompromised, consider this.

Packing should be removed in 48-72 hours in most cases

If all of the above treatments haven’t worked, namely pressure, vasoconstrictors, cautery and anterior packing, you may have a posterior bleed on your hands, especially if an anterior bleed has not been controlled within an hour. This is also something you may suspect if you can’t visualize the anterior bleed.

5-10% of epistaxis are posterior bleeds. Either from the lateral nasal wall or nasal septum coming from the sphenopalatine region of those. These may be brisk and pulsatile, which should alert you to a posterior bleed as well.

Posterior epistaxis is more common in elderly patients and is more difficult to control.

As mentioned above, First try a bilateral anterior pack. If still bleeding, use longer versions of your epistaxis balloon, such as Rapid Rhino, the 7.5 cm ones that are designed to get the posterior bleed. These usually have two balloons. Inflate the posterior one first until the mini

pilot cuff near the syringe attachment is firm and round. Give a light tug anteriorly to make sure it is snugly in place, then inflate the anterior portion. It is a separate syringe attachment.

Posterior packing is associated with higher complication rates, like pressure necrosis, infection, hypoxia and cardiac dysrhythmias. These patients are typically admitted.

If applying posterior packing, this is considered temporizing until seen by ENT.

Next step if this posterior pack isn’t working is for them to see ENT more urgently. They can help facilitate fancy things, like endoscopic ligation or arrange for endovascular embolization. 25% of posterior bleeds are refractory to usual treatment and may require endoscopic ligation.

If you are at a site without ENT, after a posterior Rapid Rhino pack, you can try a different posterior pack, like using a 14 French Foley. Cut off the tip because it can cause gagging. Push it in until visualized in the oropharynx. Inflate 7 ml air. Tug a few centimeters until inplace. If slides back down, deflate the balloon, try again with 10 ml of air. Don’t use more than 10 ml. Don’t stop here. You can’t give them an isolated posterior pack using this method, so you will need to also put in an anterior pack on this side.

As mentioned earlier, posterior packs typically need admission. Tintinalli’s says it is strongly advised to admit these patients. The documented median age of hospitalization for epistaxis is 70 years old. In line with this, most nosebleeds in ages under 10 are benign and self-limited.

Also note that the pressure applied with posterior packs can induce an intense vagal reaction so consider monitoring their heart rate, and they certainly should be admitted because of risks of hemodynamic compromise.

If packing is in for longer than 48-72 hrs, can consider amox clav to prevent possible toxic shock syndrome. There is mixed evidence behind this.

Another thing we saw on Dynamed that has fallen out of practice but that you can try in a pinch, is that you can try hot water irrigation for posterior bleeds before trying your posterior pack. This is based on a 2006 case study in the journal of Rhinology that showed it resolved posterior epistaxis in 84% of a sample of 103 patients.

This involved inflating a catheter posteriorly to avoid aspiration of water, then constantly irrigating 500 ml of 50 degree Celsius water over 3 minutes into the affected side. The idea is that the warm water causes mucosal edema, which can clamp off the bleed. The study used a

caloric stimulator, which I’m sure no one has. If you’re actually going to try this, maybe just try the old microwave trick of getting a jug of water up to temp or just find the sweet spot with the tap water.

The French Society of otolaryngologists also recommends a hemostatic glue in patients with persistent epistaxis, mainly used in patients with epistaxis following surgery or in those with coagulation disorders who are resistant to primary treatments. I’m not sure if we have heard of this being used before.

For unstable: group and screen or crossmatch. You may consider getting a hemoglobin on the patient if it has been going on for a while, like perhaps a day or longer. Use your judgment. You may also consider getting an INR. Based on INR and amount of bleeding, you can consider reversing if they are on warfarin. This is rarely needed. The need for transfusion is more common for those with a posterior bleed or who are anticoagulated. If clinical suspicion, you may get lytes, including urea and liver function tests because CKD and liver disease are associated with epistaxis. 

If a tumour is suspected, consider CT and/or MRI.

Disposition is important. All patients require some form of monitoring. As above, few need admission. Most likely, you just need to observe in the ER. Can be discharged if bleeding is controlled after 1 hour of observation.

When your patient is stable with all of the packing, they can return to emerg/primary care or ENT within 24-72 hrs for removal. Irrigate the packing with 5-10 ml of saline to soften prior to removal. Removing can be quite uncomfortable.

Provide the patient with information handouts on management and prevention. Linked below. One of them is the “Heal” resource from Alberta Health Services designed for pediatric patients.

Prevention measures include:

• moisturizing the area to prevent future bleeds using petroleum jelly.
  • In dry environments, use humidifier while sleeping.
  • Advise against nose picking lol
  • We reached out to an RT colleague of ours, who had the following recommendations for our patients on CPAP: stay hydrated, turn up the humidifier on the CPAP machine (apparently humidifiers are standard on theses), using a face mask as opposed to the nasal pillow (essentially nasal prongs), and finally, ensure minimal mask leak.

No picking or blowing nose for ≥1 week after significant epistaxis. Also avoid bending over or straining during for a week.

After managing a bleed in the ED, return to ED if bleeding, fever, increased pain, ongoing drainage.

Depending on the cause of the bleed they may need further follow-up. For example, if you suspect a malignancy, liver disease, and coagulopathy. If they are on anticoagulation, consider their indication and have them follow up with their specialist/call the internist on call.

Use your clinical judgement and review indications for stopping anticoagulation. Not all bleeds require you to stop anticoagulation, for example, the risk from epistaxis often won’t outweigh the risk of stroke for patients with Afib. We won’t get too much into indications for stopping anticoagulation in this episode.

Now you know how to properly apply pressure to their nose if this happens again!

“Epistaxis.” 2 Jan. 2022, http://www.dynamed.com/condition/epistaxis.

Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery. 2020;162(1_suppl):S1-S38. doi:10.1177/0194599819890327

Tintinalli, Judith E.,, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Ninth edition. New York: McGraw-Hill Education, 2020.

Patient information and handouts:

2015 revision of CFPC document on nosebleeds for patients: https://www.cfpc.ca/CFPC/media/Resources/Patient-Education/Nosebleeds_ENG.pdf

Heal Handout for nosebleeds in pediatrics from Alberta Health Services: https://www.albertahealthservices.ca/assets/heal/heal-handout-nosebleeds.pdf

Nosebleeds

CPAP Side Effects

Click to access NoseBleedsBloodThinners.pdf