The protocol for Epistaxis:
Epistaxis
Let’s break it down!
YES! Epistaxis is just a pretentious way of saying that the patient is having a nosebleed 🧐. For the far majority of cases, epistaxis is pretty mild and self-resolving, but every once and a while it’ll be bad enough for it to earn its fancy name 🏆
So what’s actually happening during a nosebleed? As you can see from the diagram below, there are LOTS of blood vessels that run through your nose.
It’s not super-duper important that you memorize the ENTIRE vascular anatomy, but it’s important to take note of a few spots, like Kiesselbach’s plexus, which sits towards the front of the nose. This is where 90% of all nosebleeds occur and it’s the reason why anterior nosebleeds are much more common than posterior nosebleeds. It bleeds so darn much because it’s very rich in blood vessels and it sits towards the front of the nose where it’s exposed to the arid environment, as well as your nasty fingers. A significant portion of nosebleeds are caused by “digital manipulation”….aka picking your nose 👆👃
Posterior nosebleeds are a different animal 🐒. They represent only 5-10% of all nosebleeds If you look at the diagram once more, you’ll see the sphenopalatine artery (SPA). This is the source of the MAJORITY of posterior nosebleeds. Since this area sits in the back of the nasal cavity and remains pretty well protected, these aren’t particularly common, especially in a healthy, young population 🏃♂️. A young soldier can get this, but generally, it’s the elderly population that’s more susceptible to this because their blood vessels are weakened and their blood pressure is generally higher ⬆️, causing spontaneous ruptures (although for what’s worth, the correlation between hypertension and posterior epistaxis is controversial) 🤷♂️
There is a dense mix of arterial and venous blood vessels that run through the nose so you can expect variable shades of red 🌈. The blood vessels are small though, so it’s typically slow and non-pulsatile. As you get closer to the posterior side, the blood vessels are a bit larger, which is why posterior bleeds typically tend to be more severe. If you take a look at the picture of the patient in the protocol ⬆️⬆️, you can see that these bleeds can get bad quickly.
There’s no magical division between anterior and posterior epistaxis, nor is there going to be any good criteria for you to be able to tell which one the bleed is just by looking at it 🤨. As medics, we’re not blessed with rhinoscopy equipment that will allow us to actually see where the bleeding is coming from 👀. A clean, anterior bleed might be obvious during an anterior visual inspection with a penlight or otoscope, but more than likely it won’t be as easy as that. Therefore, our diagnosis of posterior epistaxis will come as a result of the FAILURE of our initial treatments (nose pinching, Afrin sprays, nasal packing, etc.). None of those treatments will be able to effectively reach a bleed if it’s posterior…so if the bleeding continues despite those treatments, then we know it’s posterior ☑️
This is a video of a rhinoscopy being performed on a patient with posterior epistaxis. It goes through the various videos of before and after treatment so you can get an idea of what’s going on. Of all the rhinoscopy videos that I’ve watched, this is one of the more mild ones…but it gives you a good view of the anatomy 👌. Hopefully, it doesn’t confuse you more!
These first TWO things are going to be your initial go-to management for just about everybody! 🎉
For whatever reason, we still have people out there that think it’s a good idea to tilt your head back when you have a nosebleed to keep it from coming out. I hate to have to state the obvious, but the bleeding doesn’t stop just because you tilt your head back….it just bleeds down your throat instead 🙄. So pretty please, with sugar on top, tell your patients to lean forward, not back 😩
Next, we have a drug called Oxygmetazoline (Afrin) that we can use. You’ve probably used this before on yourself to treat nasal congestion from a cold or allergies. It works by acting as a peripheral vasoconstrictor, which means it narrows the blood vessels. This keeps it from secreting additional mucous and clogging up your nostrils. Since it reduces blood flow by about 50% in the nasal vessels, you can imagine how useful it is for epistaxis 👍. The key thing about giving this though is that you have to tell the patient to blow their nose first to remove the clots. This may seem counterproductive at first, but we have to remove the clots so that the Oxymetazoline can reach the blood vessels and work properly ⭐️
Then, of course, you have to tell the patient to hold it for a FULL 10 MINUTES w/o releasing pressure. Just make sure that the patient is holding their nose correctly (on the soft tissue part, not the bony part) and that the 10 minutes is ACTUALLY being timed on a watch 🕗
This treatment alone should stop almost ALL of the cases of epistaxis that present to you. But if it doesn’t…..
Like any bleed we can’t control with manual pressure, we’re going to pack it 🤜. Now the protocol states that you should use a nasal sponge, but honestly you can use a TON of different things: gauze, hemostatic gauze, tampons, whatever! The goal is to get more targeted pressure on the bleed and better delivery of the medication. As far as this protocol is concerned, that means more Oxymetazoline (Afrin). However, there is a new practice among ER Docs that includes using TXA soaked gauze for packing as well 🤯. If you think about the anti-fibrinolytic properties of TXA, you can see how this makes sense for nosebleeds 🤓
Because this is a great video on nasal packing and because I love EMRAP 😍, here’s an EMRAP video from youtube that shows some nasal packing with TXA:
After a solid 30 minutes, you can remove the gauze and see if the bleeding is still present 👀. If this was an anterior bleed, then it should most definitely work. The protocol advises instructing the patient to apply Mupirocin (Bactroban) 2-3 times a day for a few days afterward to prevent infection 🤢. Probably a good idea since we just stuffed a bunch of foreign material into their nose 😳. If you don’t have Mupirocin, then any antibiotic ointment will work just fine 👌
But if you remove the gauze and the patient is STILL bleeding, then…..
As we mentioned before, it’s only after the FAILURE of all of the other treatments that will lead us to the diagnosis of posterior epistaxis 🧐. By now, the patient has bled for at least 45 minutes so we can expect a considerable amount of blood loss. An IV with some crystalloid fluid should help replace some fluid loss (although, if it’s REALLY severe, you should treat this as a trauma patient and seek out blood products and/or administer TXA 💉).
Then, we bring out the nuclear option……the all-mighty Foley Catheter 🚀
You might find this as a surprise, but the catheter used for urinary drainage was not designed for the treatment of posterior nosebleeds (one study actually showed that physicians were surprised that this wasn’t the “standard practice” 🤪). However, it turns out to work remarkably well and ER docs continue to use it to this very day as opposed to some of the other commercial products that were actually designed to treat posterior epistaxis (ex. Rhino Rockets). For us, foley catheters are pretty much all we’re going to have 🤷♂️….so here’s how you use them to control posterior nosebleeds:
- Prepare 14 French Foley catheter. (Cut tip to minimize distal irritation)
- Advance catheter along the floor of the nose (straight in) until visible in the mouth
- Fill the balloon with 5mL of normal saline
- Retract catheter until well opposed to the posterior nasopharynx
- Add an additional 5mL of normal saline to balloon
- Clamp in place without using excessive anterior pressure
- LEAVE BALLOON AND PACKING IN PLACE FOR 72 HOURS!
When it’s all said and done, it should look like this:
Because this is kind of a confusing procedure, I found a video you can reference that shows a doctor performing it 🤔. Just watch it from 17:01-17:50. Everything else is pretty much outside of our scope… 💁♂️
And since we’re getting pretty invasive with our treatment and the patient can’t put any antibiotic ointment in their nose for about 72 hours, we’re going to give them oral antibiotics (400mg of Moxifloxacin) every day until the catheter is taken out to prevent any infections from occurring 🤢
The protocol says it all 📖. Hopefully, that foley will have fixed the problem, but don’t wait 72 hours to check it before you get them to definitive care 🚑. Epistaxis always has the potential to be dangerous! 😳
Till Next Time!
References
- Stapczynski JS, Tintinalli JE. Tintinallis Emergency Medicine: a Comprehensive Study Guide, 8th Edition. New York: McGraw-Hill Education; 2016.
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.
- emDocs: The Emergency Department Management of Posterior Epistaxis
- NCBI: Epistaxis
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