Chapter 172. Epistaxis Management

Epistaxis is an extremely common condition in the United States with an incidence estimated at 10 per 10,000 people per year.1 It is a common reason for patient visits to the Emergency Department. There is an early peak in those less than 10 years of age.2 The frequency of epistaxis decreases in the teens and begins to progressively increase after 20 years of age, with the highest frequency in the elderly.2 Epistaxis usually is the result of well-localized intranasal trauma. However, it may be the initial sign of a more serious underlying systemic illness. Epistaxis is often self-limited and can be managed conservatively. Epistaxis can also manifest itself as a profuse spontaneous hemorrhage that is extremely difficult to control and result in aspiration, hypotension, cardiovascular collapse, syncope, and airway compromise.

The proper management of epistaxis and the prevention of adverse consequences depend on a timely and thorough evaluation of the patient as well as the appropriate intervention. The Emergency Physician must be familiar with a variety of techniques to control intranasal hemorrhage.

An understanding of the vascular anatomy of the nasal cavity is essential to efficient and immediate control of nasal bleeding. The blood supply to the sinonasal cavity arises from both the internal and external carotid artery system (Figure 172-1). The sphenopalatine artery arises as one of the terminal branches of the internal maxillary artery, a branch of the external carotid system, and is the primary blood supply to the sinonasal cavities. The anterior and posterior ethmoid arteries, terminal branches of the internal carotid system, supply blood to the superior straits of the nose. The superior labial branch of the facial artery supplies the anterior nasal cavity and anastomoses with branches from the anterior ethmoid artery and the sphenopalatine artery in an area of the anterior nasal septum known as Kiesselbach's plexus or Little's area (Figure 172-2). It has been estimated that 90% of all nasal bleeding occurs in the area of Kiesselbach's plexus.3 This is particularly true for children and young adults. Older adults tend to bleed from the posterior nasal cavity, from branches of the sphenopalatine and posterior ethmoidal arteries. This has been attributed to arteriosclerosis.3

Epistaxis may result from numerous local and/or systemic factors that damage the delicate mucosal lining of the nasal cavity and expose the underlying vasculature. The most common cause of epistaxis is accidental or self-inflicted trauma, often from digital manipulation of the nasal mucosa (i.e., nose picking). This eventually heals and crusts over but is subject to repeated irritation and bleeding when the patient sneezes or blows their nose. The anterior source of this bleeding makes it very easy to treat. High-velocity trauma to the region of the midface and skull base may be manifest as a severe, life-threatening hemorrhage that may be extremely difficult to control.

Local inflammatory reactions due to acute upper respiratory infections, allergic rhinitis, and chronic sinusitis may cause epistaxis.4 The mucosa becomes inflamed, hypervascular, and is easily disrupted with forceful nose blowing. The presence of an intranasal foreign body may inflame the nasal mucosa, with consequent granulation tissue and bleeding. This should be expected if the bleeding is unilateral and associated with nasal obstruction and foul rhinorrhea.

Epistaxis may be attributed to a nasal septal deformity.5 The deflected nasal septum creates turbulent airflow that desiccates the mucosa and leads to crusting and bleeding. Epistaxis attributed to nasal septal deviation presents just posterior to the deflection and may be difficult to control. Nasal septal perforations bleed frequently and easily from mucosal irritation and granulation tissue.

Postoperative bleeding as the result of sinonasal surgery—such as septoplasty, rhinoplasty, turbinectomy, and endoscopic sinus surgery—may also be encountered. Blood-tinged nasal secretions are to be expected for the first 2 weeks after surgery. Severe epistaxis may occur during the first postoperative week, with an estimated incidence ranging from 0.9% to 8.9%.6 The bleeding is usually posterior, brisk, and may be difficult to control. Consult the Otolaryngologist who performed the procedure in all cases of postoperative bleeding.

Nasal bleeding may be the first sign of a sinonasal neoplasm. The bleeding is usually intermittent and often accompanied by nasal obstruction and pain. Severe bleeding is unusual except in the case of juvenile nasal angiofibromas, which should be suspected in adolescent males.

Patients without identifiable local causes for epistaxis most likely suffer from an underlying systemic process. Consider the possibility of a defect in the coagulation cascade. Hypertension is often cited as a significant factor for epistaxis. Studies have been unable to demonstrate a significant difference in the prevalence of epistaxis in patients with hypertension versus patients without hypertension.7,8 Nonsteroidal anti-inflammatory drugs and aspirin containing products have been associated with epistaxis.9,10 Osler-Weber-Rendu disease is an autosomal dominant inherited condition in which the blood vessel walls lack contractile elements. Consequently, prolonged heavy bleeding occurs from relatively minor insults, as the vessels are unable to contract and allow clotting to take place. The patient's coagulation profile is normal and the diagnosis is made by the family history. Other systemic etiologies include alcoholism, blood dyscrasias, liver disease, malnutrition, and pregnancy.

A patient with epistaxis must be evaluated expediently. All patients with epistaxis require a thorough examination and control of the bleeding. Epistaxis that has resolved still requires management to prevent rebleeding.

There are no contraindications to the management of epistaxis. Manage any unstable vital signs, unstable airway, life- or limb-threatening injuries, or any complications related to blood loss (e.g., hypotension, chest pain, syncope, etc.) before managing the epistaxis. In the interim, apply a nose clip or a nasal sponge/tampon to control the bleeding. A thorough examination and more definitive means of control can be performed after the patient has been stabilized.

• Nose clip
• Headlight or overhead light source
• Yankauer suction catheter
• Frazier suction catheters, #5 and #7
• Nasal speculum, short and medium lengths
• Bayonet forceps
• Kidney basin
• Weeder metal tongue blade or wooden tongue depressors
• Gown, gloves, face mask with an eye shield or goggles
• Cotton balls
• Topical anesthetics and vasoconstrictors (Table 172-1)
• Silver nitrate applicator sticks
• Petrolatum (e.g., Vaseline) impregnated gauze ribbon, 0.5 inches wide
• Synthetic nasal sponges/tampons, various lengths
• Nasal balloons (anterior, posterior, anterior and posterior)
• 14 French Foley catheter with a 30 mL balloon
• Umbilical clamp
• Gelfoam
• 4 × 4 gauze squares
• Surgicel
• ENTaxis nasal packing
• 3 inch long dental rolls or tonsil packs, or 3 × 36 inch Vaseline gauze
• Umbilical tape or 0 silk suture
• Red rubber catheters
• Lubricant

The list of equipment required to manage a patient with epistaxis is quite long. Most Emergency Departments keep all the required equipment, except medication, in a rolling cart or tackle box. This system allows for more efficient stocking and restocking. It is also more efficient to have all the required equipment readily available in one convenient and portable location. Single patient use and disposable nosebleed trays are commercially available (e.g., Centurion ENT/Nosebleed Tray, Tri-State Hospital Supply Corp., Howell, MI). They contain all the required instruments but lack the medications and other supplies.

Explain the procedure, its risks, and its benefits to the patient and/or their representative. Obtain a signed informed consent for the procedure. Ensure that the patient has a thorough understanding of the postprocedural care instructions and follow-up requirements.

Position the patient sitting in an upright multipositional procedure chair. Alternatively, place the patient sitting upright on a gurney with the back elevated. Prepare the wall suction unit to make sure that it is working. Apply suction tubing and a suction catheter to the suction source.

The importance of good lighting cannot be overemphasized. Apply a headlamp if one is available. An alternative is an overhead adjustable light source. Position the light so that it is aimed in the patient's mouth. The overhead light often hits the examiner in the head, casts shadows, and is too bright for the patient's eyes. It is also difficult to position properly as both of the examiner's hands must be used for the procedure.

Instruct the patient to blow their nose firmly, one nostril at a time, in order to evacuate the nasal cavities before the examination. This allows the anterior nasal septum, Kiesselbach's plexus, the nasal vestibule, the inferior turbinate, and the floor of the nasal cavity to be examined. Inspect the posterior oropharynx for active bleeding using the Weeder tongue blade or a wooden tongue blade. Insert a short nasal speculum to evaluate each side of the anterior nasal cavity. Open the speculum vertically. Suction out any blood and blood clots with the Frazier suction catheter. Consider a posterior site of bleeding if the source is difficult to localize. A patient will occasionally present with bilateral epistaxis. It is sometimes difficult to determine from which side the bleeding is originating. Ask the patient which side started bleeding first. This is usually the side where the bleeding point can be found.

Vasoconstrict and anesthetize the nasal mucosa (Table 172-1). Decongest the nasal mucosa with an aerosolized agent. Instruct the patient to sniff in deeply after the spray is applied. Allow 3 to 5 minutes to pass for the vasoconstriction to occur. Apply a topical anesthetic spray to the nasal passageway. Spraying achieves excellent vasoconstriction and anesthesia as the agents diffuse through the entire nasal cavity and pharynx. It is possible to anesthetize and vasoconstrict the nasal mucosa in one step by using cocaine or a combination of an anesthetic and vasoconstrictor agent (Table 172-1). Alternatively, place cocaine-soaked pledgets into the nasal cavity. Direct the pledgets along the floor of the nose, against the nasal septum, and toward the superior straits of the nose. Monitor the patient's vital signs when vasoconstrictors are applied.

There are numerous techniques to manage epistaxis. These include the use of absorbable packs, electrocautery, Foley catheters, gauze rolls, intranasal balloon catheters, petrolatum impregnated ribbon gauze, nasal tampons or sponges, and silver nitrate. The technique and material of choice depend upon the location of the bleeding (anterior vs. posterior) and Emergency Physician preference. Different techniques and equipment are required to control anterior versus posterior bleeding.

Radiologic Studies

Imaging is not routinely indicated for the initial evaluation and management of epistaxis in the majority of cases. Damrose and Maddalozzo reviewed CT scans of pediatric patients who were referred for evaluation of epistaxis.11 While 79% of the studies demonstrated some abnormality, none of the patients were found to have a neoplasm. They concluded that routine imaging of the sinuses is not recommended. CT imaging of the paranasal sinuses and facial bones should be considered when there is a history of facial trauma or when there is a high index of suspicion for a neoplasm.

Anterior nasal packing is required when local measures fail to control epistaxis. This may be due in part to anterior or structural problems in which the bleeding source cannot be identified. It may also be due to heavy or profuse bleeding. The premise behind placing nasal packing is that it provides mechanical pressure and tamponades the bleeding site.12 Note that this is an uncomfortable procedure; therefore, the previously described steps for applying topical anesthesia should be undertaken.

Absorbable Packing

Diffuse bleeding is frequently encountered in patients with coagulopathies and blood dyscrasias. The trauma of inserting the nasal packing (e.g., a tampon or petrolatum gauze) can lead to more serious bleeding. A piece of Gelfoam sponge or oxidized cellulose (e.g., Surgicel) is often effective. These substances, coated with an antibiotic ointment (e.g., Bacitracin), provide adequate pressure and hemostasis without extreme trauma to the nasal mucosa. This packing does not need to be removed and will slowly dissolve with the use of a topical saline spray, which may be started within 24 hours of the packing being placed.

The two most commonly used absorbable dressings are Gelfoam and Surgicel. Gelfoam is an absorbable gelatin sponge that is readily available and inexpensive. It forms a scaffold for the formation of a blood clot. Surgicel is composed of oxidized and regenerated cellulose. It promotes coagulation better than Gelfoam. Unfortunately, Surgicel results in delayed healing and its use should be reserved for persistent bleeding or when Gelfoam is not available.

Absorbable packs may be used for primary and secondary hemostasis. Apply a piece of Gelfoam or Surgicel directly over the site of discrete bleeding or diffuse oozing. The material may be used for secondary hemostasis and be placed over an area that has clotted and stopped bleeding. This can serve as a “Band-Aid” to help prevent the clot from dislodging prematurely and the bleeding to restart. It can be placed over areas that have been chemically or electrically cauterized. An absorbable pack can be placed prior to packing the nasal cavity with a sponge/tampon or gauze. The absorbable pack will prevent the clot from becoming dislodged when the sponge/tampon or gauze is removed.

Insert the nasal speculum and identify the scabbed or bleeding site. Apply a piece of Gelfoam or Surgicel over the site. Allow a clot to form onto the absorbable packing. The nasal cavity may then be packed with a sponge/tampon, petrolatum gauze, or a balloon catheter if the Emergency Physician chooses.

Two additional absorbable dressings are topical thrombin and collagen. They are expensive, not usually available in the Emergency Department, and should be limited to circumstances where other hemostasis methods have failed. Topical thrombin is made from bovine thrombin. Place a piece of Gelfoam saturated with thrombin over the bleeding site. Thrombin converts fibrinogen to fibrin, bypassing the coagulation cascade, to form a clot. Collagen is available in multiple forms from a variety of sources. It promotes platelet aggregation and forms a scaffold for the formation of a clot. Cover the bleeding site with collagen followed by a piece of Gelfoam.

Chemical Cauterization

The location of the bleeding is usually within the anterior nasal cavity, specifically on the anterior nasal septum. Sometimes no active bleeding is found at the time of the evaluation. Suctioning of the nasal cavity will remove clots and may allow the site to bleed and be visualized. A scabbed excoriation or an exposed blood vessel may be found along the nasal septum. Chemically cauterize these areas using silver nitrate applicators.

Insert the nasal speculum and identify the scabbed site or the exposed vessel. Apply the silver nitrate under direct vision by rubbing the applicator on the area immediately surrounding the scab or blood vessel. Apply the silver nitrate for 3 to 10 seconds. Do not apply the applicator in any one spot for more than 10 seconds. This may cause mucosal necrosis and damage to the underlying cartilaginous septum. Do not apply the silver nitrate too excessively or in the same spot on both sides of the septum, as this may result in a septal perforation. Apply a topical antibiotic ointment to the area. Consider placing a piece of Gelfoam or Surgicel over the site to help stabilize the clot.

A relatively dry field is required to use the silver nitrate applicator. Moderate-to-severe bleeding results in the silver nitrate coagulating the blood. It will not contact the mucosal tissue and bleeding will continue. Attempt to simultaneously suction the blood while using the silver nitrate applicator. Unfortunately, the suction often pulls off the coagulum and the bleeding continues. A final technique is to apply the silver nitrate centripetally around the bleeding site. This will cauterize the feeder vessels and may stop the bleeding. Do not cauterize an area over 0.75 cm in diameter, as this can result in damage to the underlying cartilaginous septum. Pack the nasal cavity with a sponge/tampon, petrolatum gauze, or a balloon catheter if these techniques fail.

Electrical Cauterization

Electrocautery can effectively control bleeding if the site is iden-tified. This technique is reserved for the experienced Otolaryngologist. It can cause significant damage to the mucosa and cartilage in inexperienced hands. The technique of electrocautery is not discussed for these reasons.

Ribbon Gauze Packing

The traditional technique of anterior nasal packing consists of using 0.5 inch wide petrolatum impregnated gauze ribbon (Figure 172-3). This technique is extremely effective but not often used as it is cumbersome, time-consuming, and simpler methods exist (e.g., silver nitrate cautery, sponges/tampons, and balloon catheters).

Insert the nasal speculum. Grasp one end of the petrolatum gauze with a bayonet forceps. Insert the petrolatum gauze into the nasal cavity and along the nasal floor (Figure 172-3A). Tightly pack the nasal cavity in a layered fashion from bottom to top, extending as far back as possible toward the choanal arch (Figure 172-3B). Be careful to avoid injuring the mucosa overlying the septum and the turbinates. Cut the petrolatum gauze so that it protrudes approximately 2 cm from the nostril. Tape this loose end to the patient's cheek so that it does not accidentally pull the packing out. The packing is later removed by gently pulling on this free end of gauze ribbon protruding from the nostril.

The pressure of one-sided anterior nasal packing can bow the septum contralaterally, allowing the packing to “loosen” and the bleeding to restart. Consider packing the contralateral anterior nasal cavity to maintain the septum in the midline and exert pressure on the bleeding site.

Expandable Nasal Sponges/Tampons

One of the easiest, quickest, and most effective techniques to control anterior epistaxis is to insert an expandable sponge or tampon (e.g., Merocel packing). These packs are particularly useful when the bleeding is diffuse, a specific site cannot be clearly identified, or the bleeding is heavy. The packs come in various sizes (4.5, 6, 8, and 10 cm), shapes, and styles (Figure 172-4). Initially quite rigid, they soften and expand with the absorption of saline or surrounding blood. A 4.5 or 6 cm sponge is generally adequate for anterior epistaxis.

Prepare the sponge/tampon. Cut the string from the sponge/tampon as it is not necessary to remove the packing. The sponge/tampon is barely visible when properly inserted. The string hanging from the nostril is irritating to the patient and not cosmetically appealing. Lightly coat two-thirds of the sponge/tampon with a non-water-soluble lubricant (e.g., Vaseline) or antibiotic ointment (e.g., Neosporin). This will prevent premature expansion of the tampon from a water-soluble lubricant or antibiotic ointment, nasal secretions, or blood.

Insert and open the nasal speculum within the affected nasal cavity. Grasp the unlubricated end of the sponge/tampon with a bayonet forceps or the dominant thumb and index finger. Insert and advance the sponge/tampon just lateral to the nasal septum, in a vertical position, with the length of the pack directed along the floor of the nose (Figure 172-5A). Advance the sponge/tampon until it is completely within the nasal cavity. The sponge/tampon will expand from the blood and secretions within the nasal cavity (Figure 172-5B). Slowly drip 1 to 3 mL of tap water or saline onto the unlubricated tip of the sponge/tampon to help it expand more rapidly.

Inspect the oropharynx for bleeding. Persistent bleeding may be due to the septum bowing contralaterally. Pack the contralateral anterior nasal cavity with a sponge/tampon of equal length and size. Observe the patient for oozing or bleeding anteriorly or posteriorly. Continued bleeding requires removal of the sponge/tampon from the bleeding nasal cavity and insertion of a larger one, two small ones, or Vaseline gauze packing.

Keep several helpful hints in mind when using the nasal sponges/tampons. Trim large sponges/tampons to 5 to 6 cm in length. The extra length is not required for anterior epistaxis, is uncomfortable for the patient, and is more difficult to remove. The Rhino Rocket is a sponge/tampon within a plastic syringe-like device. Remove the sponge/tampon from the syringe-like device before inserting it. The device can generate significant force and result in mucosal tears, septal injuries, and turbinate injuries. Insert and advance the sponge/tampon rapidly to prevent premature expansion. There is no advantage to using a non-water-soluble antibiotic ointment versus a lubricant. The antibiotic ointment is more expensive and its antibacterial activity lasts only 2 to 4 hours. Insert two sponges/tampons side by side if the patient has a large nasal cavity.

Removal of the sponge/tampon is simple and quick. Apply 1 to 2 mL of tap water, saline, or a vasoconstrictor in a dropwise fashion to the tip of the sponge/tampon in the nostril. This will thoroughly hydrate the packing and ensure that it can be withdrawn atraumatically. Allow 5 to 10 minutes to ensure that the packing is completely hydrated. Grasp the end of the sponge/tampon with a hemostat. Place a kidney basin under the patient's nose. Pull quickly and parallel to the floor of the nasal cavity to remove the packing. Epistaxis after removal is often due to dislodgement of the clot. Use an absorbable pack or silver nitrate to stop the bleeding. Look at the sponge/tampon to identify the blood spot and the location of the bleeding.

Inflatable Nasal Balloon Catheters

The development of plastic inflatable balloon catheters has simplified the management of epistaxis. The nasal balloons are easy to use and quick to place. They are available in a variety of sizes and shapes (Figure 172-6). They are available with anterior balloons, posterior balloons, or dual balloons. The anterior balloon fills the nasal cavity and acts as an anterior pack. The posterior balloon occludes the nasopharynx and acts as a posterior pack. The inflatable balloons are more expensive than other methods used to manage epistaxis. The increased cost is offset by decreased Emergency Physician contact time as compared with that required for petrolatum (e.g., Vaseline) gauze packing. The balloons have a maximal inflatable volume that is manufacturer-specific, noted on the packaging, and noted on the balloon's inflation hub.

Prepare the equipment. Select an anterior balloon catheter. A dual-balloon catheter may be used if an anterior balloon catheter is not available. Inflate the balloon with air to just below its maximum capacity. Observe and palpate the balloon for leaks. It may also be inflated in a cup of water to look for leaks. Completely deflate the balloon. Apply a lubricant over the catheter and balloon.

Insert the nasal speculum. Insert the catheter with the distal bevel toward the nasal septum. This prevents the distal end of the catheter from getting caught on the turbinates, damaging the mucosa overlying the turbinates, and causing a second source of epistaxis. Advance the catheter along the floor of the nasal cavity until just the inflation hub is protruding from the nostril (Figure 172-7). Inflate the balloon with air and 10 mL less than the maximum volume of the balloon (Figure 172-7). Do not use saline or water to inflate the balloon. Rupture of the balloon can result in aspiration if it is filled with liquid. Do not inflate the balloon with more than the manufacturer's recommended volume. If the patient complains of pain, the balloon may have been inflated larger than the nasal cavity. Slowly deflate the balloon in 2 mL increments until the pain subsides.

Observe the patient for continued bleeding. Increase the volume of the balloon to the maximum volume if the patient does not complain of pain. The balloon may cause a bowing of the septum to the contralateral side. If the bleeding continues, pack the contralateral anterior nasal cavity to keep the septum in the midline. Observe the patient for further bleeding from the nostril or into the nasopharynx. Continued bleeding suggests that the source is high in the nasal cavity or posterior. The inflatable balloons do not always fill the upper portion of the nasal cavity. Deflate the balloon, pack the high anterior nasal cavity with petrolatum gauze, and reinflate the balloon. Observe the patient for continued bleeding that would require a posterior pack, as described in the following sections.

Rapid Rhino

The Rapid Rhino Nasal Pac (Applied Therapeutics Inc., Tampa, FL) is a form of balloon catheter. The balloon is covered with a hydrocolloid fabric that is self-lubricating, easy to insert, and promotes platelet aggregation. It is available in different lengths to accommodate children, anterior epistaxis, and posterior epistaxis. It is also available in a variety of sizes in both a unilateral balloon design and a bilateral balloon design with a single inflation port. The bilateral model allows for bilateral nasal packing with a single inflation port, maintaining equal pressure on both sides of the nasal septum. Dip the fabric covered balloon in sterile water for approximately 30 seconds to prelubricate it before insertion. Insert the balloon and inflate it as described previously. The advantage to this product is the ease of insertion, minimal bleeding upon removal, and patient comfort.13

ENTaxis Nasal Packing

A relatively new anterior nasal packing is the ENTaxis (Figure 172-8). It is a natural polymer derived from seaweed and contains calcium alginate.14 The packing provides hemostasis, has healing properties, and is atraumatically inserted and removed. Hydration with normal saline activates the calcium alginate and makes it pliable. The packing expands 300% and conforms to the anterior nasal cavity. It activates platelet aggregation to provide hemostasis, keeps the nasal mucosa moist, and gels into a smooth surface that allows easy removal.

Prepare the packing. The ENTaxis is packaged in a plastic tray with a tear-off paper lid. Peel the lid completely off the tray. Fill the tray with normal saline to saturate the packing. Remove the hydrated packing from the tray. Squeeze out the excess saline from the packing.

Insert a nasal speculum. Grasp the packing on the end opposite the string with a bayonet forceps. Insert the packing along the floor of the nasal cavity. Continue to insert the packing in an accordion-like fashion until the entire packing is within the nasal cavity. The packing will expand and gel to fill the nasal cavity. Secure the string to the patient's cheek or nose with a piece of tape.

Removal of the packing is simple and quick. The packing remains hydrated and in a gelled state while within the nasal cavity. Place a kidney basin under the patient's nose. Untape the string from the patient's face. Grasp the packing with a bayonet forceps. Gently withdraw the packing from the nasal cavity.

THROMBIN-JMI

THROMBIN-JMI Epistaxis Kit (Pfizer Pharmaceuticals, New York, NY) is a topical bovine thrombin approved for the management of epistaxis. It works on sites of minor bleeding and oozing. The thrombin causes fibrinogen in the blood to clot without the requirement of platelet activation. The kit contains one vial of thrombin, one vial of diluent, a needle and syringe, and a nasal delivery device.

Open the outer packaging to reveal a sterile inner tray with the kit components. Use the syringe with the needle to draw up the saline diluent. Inject the saline diluent into the THROMBIN-JMI vial. Gently swirl the vial to mix the components and reconstitute the thrombin powder. When completely dissolved, draw the thrombin solution into the syringe. Remove the needle from the syringe and attach the nasal delivery device. Insert the nasal delivery device into the nares. Depress the plunger to spray the thrombin solution onto the nasal mucosa. Remove the device. Allow the solution to form a clot. Apply additional thrombin solution if the bleeding continues. Consider applying a piece of Gelfoam to the newly formed clot to support it.

Floseal

The Floseal Hemostatic Matrix (Baxter Healthcare Corporation, Hayward, CA) is composed of human-derived thrombin and bovine-derived gelatin. It stops bleeding fast and in up to 97% of cases.15 The thrombin–gelatin matrix begins to break down in 3 to 5 days and is gone by 7 days. Floseal does not require platelet activation, allowing it to function in patients taking aspirin and other antiplatelet medications.

Floseal is provided in components that must be mixed. The process is more complicated than other thrombin products and can take several minutes. The kit contains all of the required components and supplies. Use the 5 mL syringe and attached needle to draw up the calcium chloride solution. Inject the calcium chloride solution into the lyophilized thrombin vial. Gently swirl the vial to mix the components and reconstitute the thrombin. Draw up the thrombin solution into the syringe. Gently transfer it into the bowl in the kit. Use the empty 5 mL syringe with a female Luer lock to aspirate the thrombin solution from the bowl into the syringe. Connect this syringe to the syringe containing the gelatin matrix granules. Push the plunger to fully transfer the thrombin solution into the gelatin containing syringe. This is considered “one pass.” Transfer the gelatin–thrombin solution back and forth between the syringes for at least 20 passes. Disconnect the syringes. Attach one of the two applicator tips to the syringe containing the gelatin–thrombin solution.

Apply a small mound of the Floseal to the bleeding source. The Floseal must remain at the site for 2 minutes. Place a sterile saline-moistened gauze sponge over the Floseal mound to ensure it maintains a seal against the bleeding site. After 2 minutes, remove the gauze and inspect the site. If the gauze adheres to the clot or the Floseal, moisten it with sterile normal saline. If bleeding persists, insert the applicator tip through the Floseal mound and deliver fresh Floseal to the bleeding site. Remove any excess Floseal by gentle irrigation after the bleeding is controlled. Consider applying a piece of Gelfoam to the newly formed clot to support it.

WoundSeal

WoundSeal for Nosebleeds (Biolife LLC, Sarasota, FL) was previously marketed as NoseBleed QR. It is an over-the-counter product that comes in a variety of applications to control bleeding. It is marketed to control epistaxis and external wounds of all types. It consists of a powder containing a hydrophilic polymer and potassium ferrate. When the powder comes in contact with blood, the polymer absorbs liquid and concentrates the red blood cells and plasma proteins under the powder to form a clot. The potassium ferrate releases iron to bind the blood proteins into a clot.

The WoundSeal powder is simple to apply. Open the blister pack. Roll the tip of the applicator stick in the powder to completely coat it. Roll the powder coated applicator onto the nasal mucosa. Remove the applicator stick from the nasal cavity. Pinch the nostrils closed for 30 seconds. Reassess the nasal cavity for continued bleeding and the need for additional applications of the powder. Consider applying a piece of Gelfoam to the newly formed clot to support it.

Ankaferd Blood Stopper

Ankaferd Blood Stopper (ABS, Ankaferd Health Products LTD, Istanbul, Turkey) is a medicinal plant extract. It is approved in Turkey for the management of postsurgical dental bleeding and external hemorrhage.16 ABS is not currently available in the United States and most other countries. It induces the rapid formation of a hemostatic protein network to control hemorrhage that is not dependent upon coagulation factors and platelets.16 It has been successfully used to control epistaxis.17 ABS may provide a new method to control epistaxis in the future.

A posterior source of the bleeding must be sought when epistaxis is bilateral, brisk, and not controlled with anterior nasal packing. It is estimated that 5% of all cases of epistaxis originate from a posterior source.18 The placement of a posterior nasal pack is extremely uncomfortable. The patient may require, on some occasions, intravenous sedation and analgesia in addition to the topical anesthesia previously described. Consider spraying the patient's soft palate, uvula, and oropharynx with a topical anesthetic spray (e.g., Cetacaine). This will minimize their gag reflex during the placement of the posterior pack.

The rationale behind placing a posterior pack is that the occlusion of the choanal arch provides a semirigid buttress against which anterior nasal packing may be placed, allowing adequate hemostasis to be achieved. This buttress may be formed from either a gauze pack, a 30 mL Foley catheter, an expandable nasal sponge/tampon, or an inflatable nasal balloon catheter. From a practical standpoint, the Foley catheter and inflatable nasal balloon catheter are most easily tolerated by the patient. The inflatable nasal balloon catheter is definitely the easiest to place, as it has two balloons that serve as both anterior and posterior packs. An anterior nasal pack is always required on the side of a posterior pack. Strongly consider inserting a contralateral anterior nasal pack to maintain the septum in the midline.

Traditional (Gauze Roll) Packing

The traditional technique of posterior nasal packing involves using rolled gauze, dental rolls, or tonsil packs placed through the oropharynx (Figure 172-9). This technique is difficult, time-consuming, messy, requires many supplies, and is not well tolerated by the patient. Easier and quicker techniques exist. For these reasons, this technique is not often performed.

Prepare the equipment. Gather the required equipment on a bedside procedure table. Use 3 inch long dental rolls or tonsil packs. An alternative is to use 3 inch wide and 36 inch long petrolatum gauze. Form a tight cylindrical roll with the gauze (Figure 172-9A). Tie two pieces of umbilical tape or 0 silk suture around the pack to divide it into thirds (Figure 172-9A).

Anesthetize and vasoconstrict both nasal cavities. Apply a topical anesthetic spray to the soft palate, uvula, and oropharynx. Lubricate a red rubber catheter. Pass the red rubber catheter through one nostril and along the floor of the nasal cavity. Advance the catheter so that the tip is visible in the patient's oropharynx. Grasp the tip of the catheter with a hemostat or forceps and pull it out the patient's mouth (Figure 172-9B). Clamp the free ends of the catheter together. Pass a second red rubber catheter through the other nostril and out the patient's mouth.

Insert the posterior pack. Tie the free end of one piece of the umbilical tape or silk surrounding the packing to the distal end of one red rubber catheter exiting the patient's mouth (Figure 172-9C). Tie the knots tightly. Tie the second piece of umbilical tape or silk to the second red rubber catheter. Pull the proximal ends (i.e., the portion exiting the nostrils) of both red rubber catheters until the packing is against the choanae (Figure 172-9D). It may be necessary to place a finger into the patient's mouth and push the pack behind the soft palate and uvula if it gets caught (Figure 172-9D). Place a hemostat on both pieces of umbilical tape exiting the nostrils. Apply slight traction with the hemostat to maintain the posterior pack against the choanae. Instruct an assistant or the patient to hold the hemostat. Untie or cut the red rubber catheters from the umbilical tape or silk sutures.

Place an anterior pack and secure the posterior pack. An anterior nasal pack is always required when placing a posterior nasal pack. The anterior pack may be an expandable sponge/tampon, petrolatum gauze, or a balloon catheter (Figure 172-9E). Tie the umbilical tape or silk exiting each nostril together (Figure 172-9F). Always place a piece of cotton or gauze between the knot and the columella to prevent pressure necrosis (Figure 172-9F). Tie the umbilical tape or silk snugly but not too tight to hold the posterior pack in place and not apply pressure to the choanae or the columella. Tape the umbilical tape or silk exiting the patient's nostril and mouth to their face (Figure 172-9F).

Removal of this packing is simple and requires several stages. Remove the anterior packing. Thoroughly examine the mucosa to make sure that the epistaxis has not restarted. Suction any clots and blood from the nasal cavity. Rebleeding requires the placement of a new anterior pack if it cannot be controlled with an absorbable dressing or silver nitrate. Cut the knot, securing the umbilical tape or silk around the columella. Pull the pieces of umbilical tape or silk exiting the patient's mouth to remove the posterior pack completely.

Foley Catheter Technique

A Foley catheter may be used to provide a posterior buttress. Using a Foley catheter is easy, quick, and simple. Select a 14 French Foley catheter with a 30 mL balloon. Inflate the balloon with air. Ensure the integrity of the balloon. Some Emergency Physicians cut off the portion of the Foley catheter distal to the balloon. They believe that the distal tip is irritating to the patient and may stimulate their gag reflex. The practice of cutting off the distal tip is based purely on Emergency Physician preference. Be careful to not cut the balloon or its attachment to the catheter.

Lubricate the distal third of the Foley catheter. Insert the Foley catheter into the nostril and along the floor of the nasal cavity. Advance the catheter until the tip is visible in the patient's oropharynx. Inflate the balloon with 7 to 10 mL of air. Do not use saline, as the fluid can result in aspiration if the balloon ruptures. Withdraw the catheter to lodge the balloon against the choanal arch (Figure 172-10A). If the balloon withdraws into the nasal cavity, advance it back into the nasopharynx. Add an additional 3 to 5 mL of air and withdraw the catheter. Continue the process by adding 3 to 5 mL aliquots of air until the balloon lodges against the choanal arch. Inflate the balloon with an additional 3 to 5 mL of air and the soft palate just begins to bulge. The balloon is overinflated if the soft palate bulges or the patient experiences pain.

Place an anterior pack and secure the Foley catheter. Apply slight traction to maintain the balloon against the choanal arch. Instruct an assistant or the patient to hold the Foley catheter. Place the anterior pack using an expandable sponge/tampon, petrolatum gauze, or a balloon catheter. Place a piece of cotton or gauze against the columella and nasal ala to prevent pressure necrosis.19 Place an umbilical clamp on the Foley catheter and over the protective padding (Figure 172-10B). The clamp must hold the balloon against the choanal arch without applying pressure to the choana or columella.

Removal of this packing is simple and requires several stages. Cut the open loop of the umbilical clamp with a scissors. Open the jaws of the clamp and remove them from the Foley catheter. Always maintain a grasp of the catheter and apply slight traction to keep the balloon in place. Remove the anterior packing. Thoroughly examine the mucosa to make sure that the epistaxis has not restarted. Suction any clots and blood from the nasal cavity. Rebleeding requires the placement of a new anterior pack if it cannot be controlled with an absorbable dressing or silver nitrate. Deflate the balloon and pull the catheter out the patient's nostril.

Expandable Nasal Sponges/Tampons

Many Emergency Physicians prefer to use an 8 or 10 cm sponge/tampon rather than the other techniques of posterior packing. This technique is easy, quick, simple, and inexpensive. The technique for insertion and removal is exactly the same as for the anterior packing technique described previously. The Epistat II (Medtronic Xomed Inc., Jacksonville, FL) is a combination device with an anterior nasal sponge/tampon and a posterior balloon. It provides better posterior hemostasis than a sponge/tampon alone.

Inflatable Nasal Balloon Catheters

A dual-balloon catheter can be used when a posterior pack is required. These catheters come in many types and styles (Figure 172-6). They are expensive but easy to use and quickly placed. The smaller distal balloon obstructs the choanal arch and acts as a posterior pack (Figure 172-11). The larger proximal balloon fills the nasal cavity and acts as an anterior pack (Figure 172-11). The distal balloon holds 10 mL and the anterior balloon holds 30 mL in most dual-balloon systems. Note the manufacturer's maximum volume recommendations on the package and on the inflation ports of the balloons.

Prepare the equipment. Fully inflate both balloons with air. Observe and palpate the balloons for leaks. They may also be inflated in a cup of water to look for leaks. Completely deflate both balloons. Apply a lubricant over the catheter and balloons.

Insert the catheter with the distal bevel toward the nasal septum. This prevents the distal end of the catheter from getting caught on the turbinates, damaging the mucosa overlying the turbinates, and causing a second source of epistaxis. Advance the catheter along the floor of the nasal cavity until the distal tip is visible in the patient's oropharynx.

Inflate the distal balloon with 4 to 5 mL of air. Do not use saline or water to inflate the balloon. Rupture of the balloon can result in aspiration if it is filled with liquid. Withdraw the catheter to lodge the balloon against the choanal arch (Figure 172-11). If the balloon withdraws into the nasal cavity, advance it back into the nasopharynx. Add an additional 2 to 3 mL of air and withdraw the catheter. Continue this process until the balloon lodges or the maximum balloon volume is reached. Inflate the anterior balloon with 20 to 25 mL of air.

Observe the patient for bleeding. Inflate both balloons with additional aliquots of air until the bleeding stops or the maximum balloon volume is reached. The balloon does not always fill the high anterior nasal cavity. Deflate the anterior balloon, pack the high anterior nasal cavity with Vaseline gauze, and reinflate the anterior balloon. Place an anterior pack contralaterally if the bleeding continues to maintain the septum in the midline and apply pressure to the ipsilateral nasal cavity.

Sphenopalatine Artery Block

This technique is a last resort when an Otolaryngologist is not available, the hemorrhage is unremitting, and other methods to control the hemorrhage have failed. Local anesthetic solution is injected into the pterygopalatine canal to occlude the sphenopalatine artery. The local anesthetic solution can cause pressure necrosis of the adjacent nerves within the bony canal.

Place the patient supine with their mouth open. Apply a topical anesthetic spray to the hard palate. Identify the greater palatine foramen. Insert a 27 gauge needle into the mucosa of the hard palate, 1 cm medial to the gum line between the junction of the second and third maxillary molars. Probe this area with the needle until it falls into the greater palatine foramen. Inject 0.25 mL of local anesthetic solution containing epinephrine into the mucosa overlying the greater palatine foramen. Arm a 3 or 5 mL syringe containing local anesthetic solution with epinephrine with a 22 or 25 gauge needle. Insert the needle approximately 25 to 28 mm into the greater palatine foramen. Inject 3 mL of the local anesthetic solution.

Consult an Otolaryngologist when the epistaxis is difficult to control by the described methods, as surgical intervention is then indicated. Surgical therapy may include septoplasty, endoscopic cauterization, arterial ligation (internal maxillary artery, sphenopalatine artery, anterior and posterior ethmoid arteries, external carotid artery), or embolization.20

Epistaxis is a common childhood symptom that may prompt an evaluation in the Emergency Department. Generally, the management of a child with acute epistaxis is straightforward. The source of bleeding is from the anterior one-third of the nasal septum, just posterior to the squamous-mucosal junction in the majority of children. The etiology is often due to digital manipulation, infection, allergic rhinitis, a coagulopathy, a foreign body, trauma, medications, a neoplasm, and surgery.

The principles of management in the pediatric population are similar to those of adult patients. Active bleeding requires immediate attention. The child needs to be assessed for any hemodynamic instability or airway compromise. A brief history should be obtained during the initial stages of treatment. The minimal equipment required for initial evaluation includes a headlight, Yankauer suction, Frazier tip suction, a small nasal speculum, and a tongue depressor. Additional supplies may be required, as well. A more comprehensive list of equipment and medications has been outlined earlier in this chapter.

After managing any life-threatening injuries and ensuring hemodynamic stability, the goal is to identify the bleeding source. Apply an anesthetic and vasoconstrictor. Evacuate any remaining clot from the nasal airway and inspect the mucosa. If the bleeding source is identified, the vessel should be cauterized with silver nitrate. Once the mucosa has been cauterized, apply a thin piece of oxidized cellulose (i.e., Surgicel) or Gelfoam that has been impregnated with an antibiotic ointment over the site to help stabilize the clot. Place an anterior nasal pack if chemical cauterization fails to control the bleeding. Expandable nasal sponges/tampons are readily available and are relatively easy to place. Trim the sponge/tampon to an appropriate length prior to insertion. Consult an Otolaryngologist if the bleeding cannot be controlled, if there are concerns that the bleeding source is from a posterior location, and for any postsurgical patient.

Once the presenting symptoms have been addressed, the underlying cause should be identified and treated. For patients with epistaxis secondary to digital manipulation, antibiotics ointment and nasal saline should be used to minimize crusting and to hydrate the mucosa. Antibiotic therapy is indicated in cases of acute sinusitis and adenoiditis. Coagulopathy must be considered when a patient presents with recurrent epistaxis. Sandoval et al found that 30% of children who presented with recurrent epistaxis had a diagnosable coagulopathy.21 Von Willebrand's disease was noted to be the most common disorder identified. Serology should include a CBC, PT, PTT, and INR in patients whose history suggests heavy bleeding, recurrent bleeding, or a personal or family history of bleeding abnormalities.

The postprocedural care of patients with anterior epistaxis is just as important as the initial control of bleeding. All patients with nasal packing require prophylactic oral antibiotic therapy with adequate coverage for Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. This is due to the significant risk of developing sinusitis and toxic shock syndrome. Arrange follow-up with an Otolaryngologist within 24 to 48 hours. Remove the packing in 48 to 72 hours if the patient experienced only minimal blood loss and was hemodynamically stable.

Inform the patient that the anterior pack is “uncomfortable.” Acetaminophen will provide any required analgesia. Avoid aspirin containing compounds and nonsteroidal anti-inflammatory drugs, as they can contribute to further bleeding. Instruct the patient to apply saline nasal spray to the packing or each nostril three or four times per hour while awake. The use of a humidifier at home will aid in preventing drying of the packing or the nasal mucosa. The patient must avoid nose picking and nose blowing. Instruct the patient on the proper technique to apply pressure on the nose if bleeding restarts. Such pressure should be maintained for 20 minutes. Continued bleeding calls for a return to the Emergency Department. The patient should also return for increased nasal pain, fever, or any symptoms related to blood loss (e.g., chest pain, dyspnea on exertion, dizziness, light-headedness, presyncope, shortness of breath, and syncope).

Patients with unstable vital signs, uncontrollable bleeding, posterior packing, or serious concomitant medical problems will require hospitalization. Patients with posterior nasal packs require consultation with an Otolaryngologist and admission to a telemetry or intensive care unit. They must be monitored for respiratory distress, hypoxia, hypotension, anemia, and cardiac sequelae. It has been estimated that 40% of patients with posterior nasal packing eventually require intubation.18 The nasal ala and columella must be evaluated continually in order to prevent pressure necrosis.

Patients with a posterior nasal pack may experience hypoxemia and hypercarbia. The etiology of these phenomena, called the nasopulmonary reflex, is unknown. The PaO2 may decrease 7.5 to 15 mmHg. The PaCO2 may increase 7 to 15 mmHg. The nasopulmonary reflex is more worrisome in patients with underlying lung disease or comorbid conditions.

The complications associated with epistaxis are variable, wide-ranging, and estimated to be from 2% to 69%.22 Epistaxis may be complicated by hemorrhage, hypoxemia, hypovolemia, circulatory collapse, and airway compromise. Complications resulting from the treatment of epistaxis include nasal septal perforation, sinusitis, otitis media, toxic shock syndrome, aspiration, alar necrosis, and hypoxia from intrapulmonary shunting due to the stimulation of the nasopulmonary reflex.23

The majority of complications can be prevented by using proper technique, providing supplemental oxygen when not contraindicated, ordering appropriate prophylactic antibiotics, arranging appropriate hospitalization if indicated, obtaining an Otolaryn-gology consultation, and arranging for adequate follow-up.

Epistaxis is a common condition that affects 10% to 13% of the general population. The key to successful management includes a prompt and thorough evaluation of the patient, an accurate diagnosis of the problem, and rapid control of the bleeding. Ninety percent of cases of epistaxis stem from an anterior source and can be controlled with either chemical cautery or nasal packing. Posterior bleeding requires the use of both a posterior pack and anterior packing. All patients with nasal packing require prophylactic antibiotics to prevent sinusitis and toxic shock syndrome. Follow-up is required in 24 to 72 hours with an Otolaryngologist or the Emergency Department to remove the nasal packing.