A couple of days ago, a friend told me about an incident that had occurred on a plane where a middle-aged man was found to have epistaxis (bleeding from the nose) midway between a 4-hour flight. Although epistaxis has various degrees of severity and only a small percent are life-threatening, the sight of blood, no matter the amount, is a cause of panic and anxiety for everyone. Hence, the cabin crew was called and helped in managing the patient until the flight landed.
Some of the causes of epistaxis on a flight are dryness in the nose due to changes in cabin pressure and air conditioning. Other causes depend on patients’ previous health problems, which may include medications such as warfarin, bleeding disorders, nose-picking.
As important as it is to learn the emergency management of epistaxis in a hospital setting, often you come across a scenario such as this, in your daily life and its essential to know how to manage it, out of the hospital setting or even in the emergency department, while taking history or waiting to be seen.
The following are a few steps you can take for initial conservative management of epistaxis:
- Make sure they are breathing normally and not in any distress, asses their condition and if you think this could be a major emergency, contact the doctor or call for an ambulance
- Ask them to bend forward toward their waist while sitting up (to prevent swallowing of blood)
- Place cotton wool or tissue into the bleeding part of the nose
- Pinch the soft part (alae tightly against the septum) of the nose just above the nostrils for 10-15 minutes
- Blowing the nose to expel blood and clots
- Additionally, an ice pack can be pressed on the bridge of the nose to stop bleeding
If the following measures fail, further medical management may be advised.
Overview
Epistaxis is acute hemorrhage from the nose, nostrils, nasopharynx, and can be either anterior or posterior, depending on the source of bleeding. It is one of the most common Otolaryngological Emergencies.
Anterior bleeds are the most common, and a large proportion is self-limited. The most common site is ‘Little’s area’ also known as Kiesselbach’s plexus (Anastomosis of three primary vessels occurs in this area: the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery; and the septal branch of the superior labial branch of the facial artery).
Posterior bleeds are less common and occur from posterolateral branches of the sphenopalatine artery and can result in significant hemorrhage.
Causes of epistaxis
Nose picking, dryness, allergic or viral rhinitis, foreign body, trauma, medications (anticoagulants), platelet disorders, nasal neoplasms, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), aspirin.
Assessment and Management
- ABC approach is a standard. Fluid resuscitation in severe cases
- History: severity, duration, previous episodes, trauma, medications, family history, infections
- Initial conservative management: as mentioned earlier including spraying the nares with oxymetazoline
- Examination: mental status, signs of shock, and coagulopathy and examination of the nose
- Treatment options: Chemical cautery is usually performed with silver nitrate, Nasal Packing, Nasal Tampons, Gauze Packing, Nasal Balloon Catheters, Tranexamic acid, Thrombogenic foams and gels
- Treatment specific to posterior bleeds : Balloon catheter, Foleys catheter, Cotton Packing
References and Further Reading
Alter Harrison. Approach to the adult epistaxis. [December 24th, 2019] from: https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis
