General Medical Officer (GMO) Manual: Clinical Section: Epistaxis

Introduction

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The key to obtaining hemostasis in the bleeding nose is to understand the anatomical etiology of the bleeding source and to exclude concomitant factors, which would inhibit natural hemostatic capability.

Anatomy

Tributaries of the external carotid system (facial, internal maxillary) supply the anterior nasal cavity whereas the posterior nasal cavity is supplied by the internal carotid system (ethmoid arteries). The area of the anterior nasal septum (Kiesselbach's plexus) is where a plexus of anastomotic vessels can be found. This area is the source for nearly 90 percent of all cases of nasal bleeding. These bleeding episodes are usually incited by local intranasal factors such as deviated nasal septum with crusting, drying, and subsequent ulceration. Posterior bleeding is more troublesome, difficult to identify, and more challenging to control.

History

When confronted with a patient with a bleeding nose, first consider the following possibilities:

Is the bleeding due to trauma?
If so, are there associated craniofacial injuries?
Is the patient stable or does he or she require resuscitation?
Are medications or medical disorders interfering with the patients ability to stop bleeding?

Supplies

Collect and arrange the following items:

light source
head mirror
nasal speculum
bayonet forceps
topical vasoconstrictor such as cocaine HCL 4% or (1:1 mixture of 1% phenylephrine and 4% lidocaine solution)
suction tip
AgN03 applicators
Vaseline gauze
#14 French, Foley catheter, or EPISTAT balloon.

Evaluation

Use of the head mirror frees up both hands so you can get exposure with the nasal speculum and locate the source of bleeding. Initially, have the patient blow all of the clotted blood from their nose. This will most likely aggravate the bleeding so be ready with the suction and nasal speculum. After a first quick look, place a cotton pledgett soaked with a vasoconstrictor in both sides of the nose and leave for 5-10 minutes. The second look will usually lead to identification of the bleeding source. If the source is identified, cauterize by holding a silver nitrate (AgN03) applicator firmly over the bleeding source for 15- 30 seconds. Repeat 2-3 times as needed. Other techniques of mechanical hemostasis include a through and through septal stitch, electrocautery, injection with adrenaline containing local anesthetic, or packing.

If all attempts to stop bleeding have failed, pack the nose. Use Vaseline gauze, Nu-Gauze with bacitracin ointment, rolled telfa, or packing sponge. An alternative is to squeeze a tube of bacitracin into the nasal cavity and place a drip pad. If bleeding continues despite appropriate anterior nasal packing, then a posterior nasal bleed may be the source. The easiest posterior pack to place is a lubricated #14 French Foley catheter into the nasopharynx. Inflate the balloon with 10-15cc of saline and pull forward and secure at the nostril with an umbilical clamp or hemostat. Take care not to cause pressure necrosis of the columella.

For any nasal pack left in place over 24 hours an anti-staphylococcal antibiotic should be used to prevent staphylococcal overgrowth and possible toxic shock syndrome (although rare). For posterior packs, sedate and manage your patient under observation. Humidified oxygen and hydration will make the patient comfortable while the packs are in place. Valium can help reduce anxiety.
The anterior packs should be left in place for 24-48 hours and the posterior packs longer, usually 48-72 hours. After pack removal, keep the patient on a local vasoconstrictor (Afrin) for an additional 72 hours and use saline nasal spray for moisture. Follow-up is important to assure a thorough exam after resolution of the bleeding. Rule out polyps, tumors, or intranasal deformities and refer to an otolaryngologist as needed for definitive management.

Reference

Deweese and Saunders, Textbook of Otolaryngology, 1994.

Prepared by LCDR David A. Bianchi, MC, USN, Department of Otolaryngology, National Naval Medical Center, Bethesda, MD. Reviewed by CAPT David H. Thompson, MC, USN, Department of Otolaryngology, National Naval Medical Center, Bethesda, MD. (1998).

Preface · Administrative Section · Clinical Section

The General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C., 20372-5300

This web version of The General Medical Officer Manual, NAVMEDPUB 5134 is provided by The Brookside Associates Medical Education Division. It contains original contents from the official US Navy version, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense. All material in this version is unclassified. This formatting © 2006 Medical Education Division, Brookside Associates, Ltd. All rights reserved.

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