EPISTAXIS - bleeding from the nose.

Causes:

The most common causes are idiopathic and hypertension.

Common sites of haemorrhage:

• Anterior nasal haemorrhage - commonly Little's area (a region of multiple arterial anastamosis within the nose).
  
• Posterior nasal haemorrhage - commonly from branches of sphenopalatine artery.

Treatment:

The majority of patients present as emergency cases. The immediate treatment is to try and arrest the bleeding and stabilise the patient as follows:-

1. FIRST AID TREATMENT:

• Apply ice packs to bridge of nose and on the back of the neck. This helps to constrict the bleeding vessels.
  
• Apply pressure - "compress the nostrils against the septum between finger and thumb, thus controlling bleeding from Little's area" (Serra, 1986).
• Encourage patient to sit forward and spit out any blood into a receiver.
• Record pulse, blood pressure, respiratory rate and temperature.
• Bloods may be taken for full blood count, group and save, urea and electrolytes - the tests done will be determined by patient's medical history or other underlying causes.
• Insert intravenous cannula to enable fluid replacement if appropriate.

In minor epistaxis, the above treatment is sometimes enough to control the bleeding and after observation for a couple of hours, if no further bleeding has occurred, the patient may be allowed to go home.

If bleeding is not stopped by the above first aid treatment, and a bleeding point is visible, it may be possible to cauterise the bleeding vessel with a silver nitrate stick. If the bleeding point is not visible nasal packing will be required.

The type of packing used depends on whether the bleeding is anterior or posterior. Individual ENT units may have local policies regarding types of packing to be used. Cost may also be a contributing factor to the type of packing used.

2. TYPES OF NASAL PACKING:

• BIPP packs - ribbon gauze soaked in Bismuth Idoform Paraffin Paste
  
• Glove finger packs with paraffin gauze inside
• Merocel packs - sponge-like packing
• Kaltostat rope
• Inflated balloons - Brighton balloons; epistat nasal catheters
• Post-nasal packing - general anaesthetic required to insert this pack

3. PACKING THE NOSE:

• The following are required: suction, tilleys forceps, thuddicums nasal speculum, receiver, 10ml syringe if using balloon, nasal local anaesthesia, tissues, nasal bolster.
  
• Suction is used to try and provide a clear view.
• Local anaesthesia is applied to the nose. This may be one of the following: Cocaine 10%; adrenaline 1:1000; xylocaine nasal spray
• Pack is inserted. Despite local anaesthesia, this is a very uncomfortable procedure for the patient. Reassurance is required +++.
• If using BIPP or glove fingers, a nasal bolster may be applied following pack insertion.
• Following nasal packing, the patient will usually be admitted to hospital.
• Packs usually remain insitu for 48 hours. If patient has experienced no further bleeding after this the pack may be removed.

4. NURSING CARE:

Once the patient has been admitted to the ward, the following points need to be considered:

• Position of patient - upright position.
  
• Observation of vital signs. Observe for signs of further bleeding. If continuing to bleed from posterior, signs may not be visible, but patient may complain about blood trickling down the back of his throat.
• Fluid replacement - intravenously
• Management of hypertension (if appropriate)
• Bed rest
• Use of minor sedation - i.e. diazepam
• If post-nasal pack insitu, prophylactic antibiotics should be given. Note: also use for anterior packs if in longer than 48 hours.

5. UNCONTROLLED BLEEDING:

If posterior nasal packing has been unsuccessful and the patient continues to bleed, then a formal examination under general anaesthetic will be required.
One of the following procedures may be performed:

• Insertion of post-nasal pack
  
• Diathermy to obvious bleeding point
• "Arterial ligation of the anterior ethmoidal artery via an external ethmoidectomy approach (if the haemorrhage is from above the middle turbinate)" (Dhillon/East, 1994)
• Ligation of maxillary artery if the bleeding is inferior.
• Ligation of external carotid artery - in extreme cases.

Following surgery, the patient would require standard post-operative management as per nasal surgery. The packs will usually stay in for a longer period. Antibiotic cover would be required. Particular observation to airway, respiratory rate and oxygen saturations will be required if post-nasal pack is insitu.

References/Suggested Further Reading:

Karen Sumpter
Lead Nurse
Head & Neck Directorate
North West London Hospitals NHS Trust
karen.sumpter@nwlh.nhs.uk