Epistaxis update management & Treatment from: AAFP, Uptodate 2017

1. EPISTAXIS
BY: DR. TAYEB THOBAB , FAMILY MEDICINE SPECIALIST.
DR. TAHER KARIRI , FAMILY MEDICINE SPECIALIST.

2. OBJECTIVES
• Epidemiology
• Anatomy
• Etiology
• Approach and Management.

3. EPIDEMIOLOGY
• Up to 60% of the general population.
• only 10% or fewer seek medical attention.
• Bimodal age distribution, before age 10 or between 45 and 65 years of age.
• Seasonal variation, with predominance in winter months.

4. ANATOMY

5. ANATOMY
• Epistaxis may be classified as anterior or posterior, depending upon the source
of bleeding.

6. ANATOMY
• Anterior bleeds — the most common.
• A large proportion is self-limited and can be
managed definitively in the primary care
setting.
• Up to 90% occur within Kiesselbach's plexus.

7. • Posterior bleeds:
• Can result in significant hemorrhage.
• Most patients require prompt referral to an
emergency department.

8. COMMON CAUSES OF EPISTAXIS
LOCAL CAUSES
• Epistaxis digitorum (nose picking)
• Trauma
• Dryness
• Chronic sinusitis, Rhinitis
• Foreign bodies
• Irritants (e.g., cigarette smoke)
• Medications (e.g., topical
corticosteroids)
• Septal deviation, perforation
• Vascular malformation or
telangiectasia
• Intranasal neoplasm or polyps
• Aneurysm of the carotid artery.

9. COMMON CAUSES OF EPISTAXIS
SYSTEMIC CAUSES
• Hypertension
• Liver disease (e.g., cirrhosis)
• HIV
• Medications (e.g., aspirin, warfarin,
NSAID)
• Alcohol
• Hemophilia
• Platelet dysfunction
• Thrombocytopenia
• von Willebrand disease
• hereditary hemorrhagic telangiectasia
(OWR)
• Leukemia

10. EVALUATION
• Initial assessment:
• Should focus on ABC.
• Airway intervention, fluid resuscitation, and emergent otolaryngologic
consultation can be necessary in severe epistaxis.

11. INITIAL TAMPONADE
• Properly instructed patients may achieve hemostasis unassisted while the
evaluation gets underway. The following approach may be helpful:
Patient blows their nose to remove blood and clots.
Clinician sprays the nares with oxymetazoline.
Patient pinches the alae tightly against the septum and holds continuously for 10
minutes.

13. HISTORY
• Interduce yourself
• Establish rapport
• C/O: duration, site, onset, timing, severity, previous episodes.
• Any trauma, exposure to extreme weather or altitude changes.
• Any ongoing problems: rhinitis, sinusitis, hypertension, bleeding disorder, liver
disease.
• Any medications: nasal steroids, aspirin, warfarin, clopidogrel.

14. HISTORY
• ICEE
• Family and social history:
bleeding disorders, abuse or domestic violence, smoking, cocaine, alcohol

15. PHYSICAL EXAMINATION
• General examination
• vital signs, mental status, and airway of any patient with significant bleeding.
• looking for signs of airway compromise or hypovolemic shock.
• signs of coagulopathy (eg, ecchymoses, petechiae, telangiectatic lesions).

16. PHYSICAL EXAMINATION
Before examining the nose:
The nasal cavity should be anesthetized.
cotton swabs soaked in an anesthetic and vasoconstrictive agent e.g:
• 2% lidocaine, lidocaine with epinephrine.
• Oxymetazoline nasal preparation, can provide vasoconstriction.

17. EXAMINATION OF THE NOSE
• Head of an examination table to upright so the patient can sit
comfortably while head movement is restricted.
• Ask the patient to look directly ahead and attempt the sniffing position.
• Use nasal speculum. with good light.
• Clots may be cleared either with suction or by asking the patient to
gently blow his or her nose.

18. EXAMINATION OF THE NOSE
• Inspect the area of Kiesselbach's plexus first
• Look closely for bleeding, ulceration, or erosion.
• Also inspect the nasal vestibule, septum, and turbinates for sources of bleeding.
• If bleeding site cannot be identified. In such cases, bleeding may be from a
posterior source or minor injury that already resolved.

20. INVESTIGATIONS
• CBC
• PT, PTT, INR
• Coagulation factors.
• crossmatch should be obtained in the setting of massive or prolonged
hemorrhage.
• LFT if indicated

21. TREATMENT OF ANTERIOR BLEEDING

22. BLEEDING STOPS WITH CONSERVATIVE
MEASURES
• If no anterior source is evident and bleeding has stopped.
• It is reasonable to observe the patient for approximately 30 minutes for
recurrent bleeding. Such patients should be discharged with antibiotic ointment.
• The nose should be packed only if bleeding recurs rapidly.

23. CAUTERY
• If an anterior bleeding source is visualized, first-line treatment consists of chemical
or electrical cautery. After applying anesthetic.
• Chemical cautery is usually performed with silver nitrate sticks.
• Cautery is applied for a few seconds (no longer than 10 seconds), until a white
precipitate forms.
• antibiotic ointment with a fingertip or cotton swab three times daily for three days.

25. NASAL TAMPONS
• Nasal packing is most easily accomplished with a
nasal tampon.
• Coat the tampon with bacitracin ointment to
facilitate placement, and possibly decrease the risk
of toxic-shock syndrome.

26. GAUZE PACKING

27. NASAL BALLOON CATHETERS

28. THROMBOGENIC FOAMS AND GELS
• As effective as cautery and packing.
• caution in patients in whom the potential dangers of systemic thrombosis are
high
(eg, known coronary or cerebrovascular disease).

29. THROMBOGENIC FOAMS AND GELS
• Floseal.

30. THROMBOGENIC FOAMS AND GELS
• tranexamic acid (TXA).

31. THROMBOGENIC FOAMS AND GELS
• Gelfoam

32. THROMBOGENIC FOAMS AND GELS
• Surgicel

33. THROMBOGENIC FOAMS AND GELS
• Avitene.

34. PERSISTENT BLEEDING
• the contralateral naris may be packed, thereby providing a counterforce to
promote tamponade.
• If bilateral anterior packing fails to produce hemostasis, the odds of a posterior
source increase greatly.

35. ANTIBIOTICS AND TOXIC SHOCK SYNDROME
• 16 per 100,000 packings.
• Be alert for signs of toxic shock syndrome (fever, hypotension, desquamation, and mucosal
hyperemia).
• Abs should not be given routinely for prophylaxis.
• It may be reasonable to treat patients at greater risk of infection, such as those with diabetes,
advanced age, or immunosuppression.
• If prescribed, an antibiotic with staphylococcal coverage should be selected, such
as amoxicillin-clavulanate or a second-generation cephalosporin; topical mupirocin may also
be used.

36. FOLLOW-UP
• If vital signs and respiratory function remain normal after packing.
• the patient may be safely referred for specialist follow-up in 24 to 48 hours, with
advice to present to an emergency department sooner if bleeding recurs.

37. PREVENTION
• Sleep in a humidified environment.
• A topical antibacterial (eg, mupirocin) or bacteriostatic (eg, bacitracin) ointment
may be gently applied to the nasal mucosa with a cotton-tipped swab in an
attempt to prevent recurrence.
• Directing nasal medication sprays away from the septum may decrease the risk
of epistaxis.

38. TREATMENT OF POSTERIOR BLEEDING
• Prefer balloon catheters.
• If balloon catheters are not available, alternatives include a Foley catheter and
cotton packing.

40. COTTON PACKING

41. HOSPITALIZATION
• Most patients with a suspected posterior source of bleeding.
• Patients with anterior packing who cannot be reasonably expected to return for
prompt follow-up or who have serious comorbidities or concerning symptoms.
• Prolonged retention of nasal packing (greater than 72 hours) - necrosis, TSS,
sinus or nasolacrimal infections, and dislodgment.

42. COMPLICATIONS
• 3% complication rate, include:
• synechiae (intranasal adhesions)
• Aspiration
• angina,
• myocardial infarction
• hypovolemia.

43. TREATMENT FAILURES
• Surgical treatment is often performed endoscopically and can include ligation of
the sphenopalatine or anterior ethmoid artery.

44. • Angiographic embolization is increasingly common, The rate of severe
complications (eg, stroke, blindness) with embolization is approximately 4%.

46. THANK YOU
• Any questions?

47. REFRENCES