Management of acute epistaxis

Prehospital management

Patients should be assessed promptly by a doctor if bleeding persists for more than 20 minutes despite the above measures, if they are uncooperative, receiving anticoagulant therapy, or clinically unwell (5–7). The patient should then, independently or with assistance, adopt an upright, forward-leaning position and pinch the nostrils, while equipment is prepared and initial assessment is undertaken (Figure 3). The patient can be covered to limit blood soiling, and the clinician should use appropriate protective equipment. If the situation allows, information should be obtained regarding the volume and laterality of bleeding, comorbidities, medication use and any previous nasal or facial surgery or trauma. In non-life-threatening bleeding in patients receiving anticoagulant therapy, local measures are recommended as first-line treatment, with consideration of temporary interruption of anticoagulation rather than prolonged discontinuation or reversal (1).

The nasal cavity should be examined under good lighting using a nasal speculum. Suction can be used if available. The posterior pharyngeal wall should be examined using a tongue depressor, both at presentation and after bleeding from the nostrils has ceased, to check for possible posterior bleeding. Although epistaxis is normally uncomplicated, substantial blood loss can occur, and posterior bleeds in particular can compromise the airway. In patients showing signs of major blood loss or general clinical deterioration, a systematic assessment according to the ABCDE approach should be undertaken. Vital signs should be measured, and the patient's clinical condition assessed. Where appropriate, intravenous access should be established early, and arrangements made for rapid transport to hospital.

Local anaesthetic is useful before painful procedures and can be administered using moistened cotton strips (Video 1). Anaesthetic agents containing adrenaline also have a haemostatic effect and improve visualisation of the bleeding site. Tranexamic acid can be used in addition to adrenaline and xylometazoline (1, 2, 8) and administered orally, intravenously or topically within the nasal cavity. A moistened gauze swab or anterior nasal pack can be applied to reduce the risk of rebleeding and as an adjunct to other measures (8).

If the bleeding site can be identified, cauterisation may be attempted. Outside hospital settings, chemical cauterisation, for example with silver nitrate, is commonly performed, whereas electrocauterisation, which has a lower failure rate, is generally available in hospitals (2). Both techniques require relatively dry conditions and adequate visualisation. When using silver nitrate, it is advisable to first cauterise the mucosa surrounding the bleeding site, as direct application to the bleeding site can trigger further bleeding (Video 1). Excessive cauterisation can cause cartilage injury and septal perforation and should therefore be restricted to one side of the septum. If necessary, treatment of the other side can be undertaken after mucosal healing. Particular caution is needed in patients with underlying conditions predisposing to mucosal injury (2). Following chemical cauterisation, application of a moisturising or lubricating agent can reduce postoperative crusting (1).

In more diffuse bleeding, non-resorbable nasal packing may be appropriate. This can also be used as an adjunct following cauterisation. A narrow strip of gauze is often used for this. The gauze strip may be impregnated with an ointment such as Terra-Cortril (Terra-Cortril, Pfizer). The nasal cavity is then packed in layers using the impregnated gauze strips (Video 1). It is important to insert the strips parallel to the nasal floor, ideally building the packing upwards towards the nasal roof. Merocel (Merocel, Medtronic Xomed) is a non-resorbable expanding nasal pack composed of polyvinyl foam, which can be lubricated with Terra-Cortril ointment or petroleum jelly to facilitate insertion. The pack is inserted parallel to the nasal floor, if necessary with slight elevation of the nostril (Video 2). On contact with fluid, the material expands, producing a tamponade effect.

Non-resorbable nasal packing can remain in place for 1–3 days before being removed by the patient or healthcare personnel. Beyond three days, prophylactic antibiotics are often recommended, although the evidence base for this is limited (1).

A common alternative in the prehospital setting is Rapid Rhino (Rapid Rhino, Smith & Nephew), which is a nasal pack coated with carboxymethylcellulose and containing one or more inflatable balloons. The pack is moistened in sterile water for 30 seconds and then inserted along the nasal floor (Video 3). The balloons are then inflated with air using a 20 mL syringe. The pressure is checked after 15–20 minutes and adjusted if necessary. The pressure should be sufficient to stop the bleeding without placing undue stress on the mucosa and cartilage, as this can result in tissue necrosis. The nasal pack is removed after 24–72 hours.

Insertion of resorbable materials is often less uncomfortable for the patient and relatively straightforward to perform (Video 4). It is also associated with a lower risk of rebleeding, as can occur upon removal of non-resorbable materials (1). This method is therefore particularly suitable for patients with underlying conditions predisposing to mucosal injury and for those unable to fully cooperate, such as children or patients with cognitive impairment (2). Resorbable materials can also be used as an adjunct to concurrent cauterisation.

If other measures are unsuccessful, posterior nasal packing can be a potentially life-saving intervention (Video 5). The procedure is commonly performed using a urinary catheter passed through the nasal cavity into the oropharynx. The catheter balloon is inflated with 4–5 mL of water, and the catheter is then drawn forward until the balloon becomes lodged in the nasopharynx. The balloon volume is adjusted according to whether bleeding is observed along the posterior pharyngeal wall. An anterior nasal pack is then placed alongside the catheter, for example using impregnated gauze strips. The catheter is secured at the nostril with a clamp, with gauze placed between the clamp and the nasal ala to prevent pressure necrosis. Balloon pressure should be titrated to the minimum effective level in order to avoid mucosal pressure necrosis.

Collaboration between prehospital services and hospitals is central to the management of patients with epistaxis. Specialty registrars are expected to learn interventions such as anterior nasal packing, but access to supervision and clinical exposure is likely variable. Structured training and, where appropriate, job shadowing in otorhinolaryngology departments for out-of-hours primary care doctors may help improve expertise and improve collaboration between levels of care.