PROCEDURE TITLE: Management of Epistaxis in the ED

FACILITY DOCUMENT NO: ED Specific Guideline

PROCEDURE TITLE: Management of Epistaxis in the ED

Facility Procedure Number: ED Specific Guideline Procedure Title: Management of Epistaxis in the ED Page 1 of 15 Version: 1.0

This is a confidential document for the use by Joondalup Health Campus only - not to be reproduced or otherwise used without the permission of Joondalup Health Campus.

CONTROLLED DOCUMENT

Joondalup Health Campus recognises that the principal responsibility for a patient’s care lies with that patient’s doctor. Following consultation with doctors and clinical employees, and through reference to current industry best practice standards, we have developed this procedure as a minimum standard designed to deliver optimal care to patients.

Keywords/search terms

Epistaxis, nasal packing, removal of nasal packing

PROCEDURE SCOPE

This document applies to: Medical officers, RN, EN in ED

PROCEDURE PURPOSE

Management of epistaxis

CONTENTS

• Background

• Assessment of Epistaxis

• Management of Epistaxis

o Equipment

o Conservative Management

o Nasal Sprays

o Chemical Cautery

o Nasal packing

o Posterior Epistaxis

• Removal of Packing in ED

• Advice for Patients being Discharged

• Special Circumstances

o COVID-19 / Pandemic

o Pregnancy

o Paediatric Patients

o Specific Circumstances

• Referral Guidance

• References and Flowchart





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EQUIPMENT

• Suction with Yankeur sucker

• Bright light source

• Co-Phenylcaine forte 50mL spray with disposable plastic nozzle

• Single use Oxymetazoline spray

• IV Tranexamic solution (1000mg/10mL)

• Lubricant gel

• Disposable container or kidney dishes

• Sodium Chloride 0.9% 10mL (for irrigation)

• Silver nitrate applicator

• Rapid Rhino nasal balloons (5.5cm, 7.5cm, 9cm) with 30mL sterile water

• Merocel nasal tampon

• Foley’s catheters (size 12/14 gauge) with 10mL sterile water for balloon

• Umbilical clamp

• Thudicum Nasal Specula (medium and large)

• Tongue Depressors

• Cotton pledgets

• Airway and resuscitation equipment

PROCEDURE

Background Epistaxis is common. 60% of people will endure at least one nosebleed in their lifetime, peaking in incidence in children under 10 years, and adults 50-80 years old. Whilst the majority of episodes will settle at home with simple first aid, around 6% will present to the ED, estimated to be approximately 0.5% of the ED workload. Serious complications, although rare, can result from epistaxis or its ED management. These include hypovolaemia, anaemia and toxic shock syndrome. Early recognition and assessment, with prompt intervention is crucial. Assessment of epistaxis includes identifying patients requiring urgent interventions and resuscitation, identifying the location and cause of the epistaxis, and documentation of treatment options and effects. The aetiology of epistaxis can be complex and multi-factorial, and an anatomical understanding can help guide treatment decisions. The vast majority of non-traumatic epistaxis occurs anteriorly at the site of Kiesselbach’s plexus, an area of anastomoses involving the terminal branches of the internal and external carotid arteries, commonly known as ‘Little’s area’. This area is prone to bleeding from drying and digital trauma.





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Posterior epistaxis occurs mainly in the elderly population, accounting for 5 – 10% of cases, and generally stemming from branches of the sphenopalatine and descending palatine arteries. Located deeper in the nose, epistaxis posteriorly is difficult to control, usually requiring specialty referral. Bleeding from the superior nasal cavity is rare, involving branches of the anterior or posterior ethmoid arteries. Management of any patient with epistaxis should take into account the underlying location and aetiology, recognising that further investigations are warranted in specific circumstances.





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~90% of patients presenting to ED can be managed with simple measures and discharged home. The other 10% will require a stepwise approach. Option include:

• Adrenaline, phenylephrine or oxymetazoline sprays or topical tranexamic acid

o Can be ineffective in profuse epistaxis, and have systemic side-effects, particularly in patients

with IHD or poorly controlled hypertension

• Chemical cautery (silver nitrate sticks)

o Not suitable where epistaxis is uncontrolled, and generally requires a clearly identifiable point

of bleeding

• Packing the nose using an inflatable or dry hydrophilic tamponade device

o Can be quite uncomfortable, and has multiple complications including: -

▪ Damage to already fragile nasal mucosa

▪ Pressure necrosis to mucosa or cartilage

▪ Obstruction of sinuses +/- sinusitis

▪ Infections such as otitis media and toxic shock syndrome (fever, hypotension,

desquamation, and mucosal hyperaemia)

▪ Hypoxia or OSA

▪ Syncope from triggering neurogenic reflexes

▪ Aspiration of packing material

Assessment (refer to flow chart)

• See pandemic guidance (below) if any concerns regarding COVID-19

• In all circumstances, appropriate PPE should be donned

• Assess and document an initial primary assessment, including for c-spine injuries or life threatening

injuries. If haemodynamically unstable, altered consciousness, syncope / pre-syncope or significant

comorbidities, the patient should be assessed and managed in the resuscitation area

• Otherwise, sit the patient upright to protect the airway

• Establish the site (anterior or posterior) and side of bleeding. This is key to appropriate management

• Implement simple first aid measures where appropriate including compression and ice

• Obtain history, including PMHx, all medications (herbal medications such as ginseng can inhibit platelet

function), recent drug use (steroid sprays, tobacco smoke and inhaled drugs such as cocaine can cause

dryness and irritation of the mucosal lining), details of current epistaxis (timing, frequency, severity,

location, estimated blood loss, etc), and any recent trauma





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• Examination (separate to the initial assessment) should include a full set of observations, visualisation

of the oropharynx, assessment for facial trauma or deformities, and assessment for additional injuries

or sources of bleeding

• Consider bloods, cannula, x-match and imaging dependant on the above assessment

Management (refer to flow chart)

1. Simple conservative management: -

a. Apply direct pressure by compressing the nares with thumb and index finger for 15 -20 min. Tilt

the head forward to prevent blood pooling in the pharynx. Apply an ice-pack to the bridge of

the nose and nape. Assist the patient in compressing as needed





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b. Stay calm, relieve patients anxiety, provide reassurance

c. Instruct the patient to expectorate blood into a receptacle such as a bowl/kidney dish, or

emesis bag

d. Keep patient fasted until bleeding is controlled

e. The role of hypertension in epistaxis is unclear. However, control malignant hypertension (i.e

oral or IV antihypertensives, GTN infusion, etc). Aim for a systolic BP < 160 mmHg

f. Reverse anticoagulation if bleeding uncontrolled and safe to do so

g. Consider an anxiolytic medication, such as lorazepam (oral or IV)

2. Nasal sprays and solutions (generally readily available in ED). Options include either of the following:

a. Co-phenylcaine forte

i. Avoid if history of IHD, malignant hypertension or sulphur allergy. Consider

oxymetazoline

ii. Seat the patient in an upright position

iii. Administer using a disposable plastic nozzle or via a soaked cotton pledget

iv. If spraying, then ~2 – 4 sprays (adult) in the relevant nostril, aiming towards the

posterior pharynx and away from the septum

v. If using a cotton pledget, then ask the patient to compress the nostril tight for 5 – 10

minutes once inserted. Gently remove from nostril afterwards

vi. Provides topical anaesthesia (takes 3 – 5 mins for effect) and local vasoconstriction

b. Oxymetazoline spray

i. Seat the patient in an upright position

ii. Administer using a disposable plastic nozzle or via a soaked cotton pledget

iii. If spraying, then ~2 – 4 sprays (adult) in the relevant nostril, aiming towards the

posterior pharynx and away from the septum

iv. If using the cotton pledget, then ask the patient to compress the nostril tight for 5 – 10

minutes once inserted. Gently remove from nostril afterwards

v. Provides local vasoconstriction only

c. Topical tranexamic acid (100mg/mL IV solution)

i. Seat the patient in an upright position

ii. Administer via a soaked cotton pledget or soaked Merocel nasal tampon

iii. Atomisation and compression may be an option if cotton pledgets not available

iv. Ask the patient to compress the nostril tight for 15 – 20 minutes once inserted. Remove

gently from the nostril

v. Has an antifibrinolytic effect with evidence suggesting fewer episodes of re-bleeding

and greater patient satisfaction. May be particularly useful in patients with HHT, or on

DOACs

vi. Exercise caution in patients with higher risk of venous thromboembolism





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d. Adrenalin 1:100,000 with lignocaine 1% (Xylocaine 1%)

i. Sprayed or dripped in the nostril, or applied via a soaked cotton pledget

ii. Effective but increased risk of systemic absorption and side-effects. Avoid if hx of IHD or

malignant hypertension

iii. Provides topical anaesthesia and local vasoconstriction

3. Chemical cautery

a. Only suitable if minimal bleeding and bleeding point clearly visible

b. Clear the nose of clots (patient to blow nose, or clinician to gently suction)

c. Ensure adequate topical anaesthesia

d. Apply adrenaline soaked pledget to area for five mins

e. Cauterise bleeding point directly

f. Avoid cauterising large areas and remove excess silver nitrate with a cotton swab

g. Apply for a few seconds (no longer than 10 seconds), until a white precipitate forms

h. Avoid overzealous cautery of the septum, which can lead to ulceration and perforation

i. Do not cauterise both sides of the septum

j. The bleeding point itself cannot be cauterised until there is relative haemostasis

k. Do not ‘wet’ the silver nitrate sticks with water, which leads to dripping onto other facial

surfaces such as the lips, leading to discolouration and pain

l. Post cautery, patients should apply antibiotic ointment with a cotton swab three times daily for

three days





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• Nasal Packing

o Rapid Rhino (5.5cm for anterior epistaxis, or 7.5 / 9cm for posterior epistaxis)

▪ Position patient sitting head up, with head tilted forward

▪ Administer topical anaesthetic

▪ Soak Rapid Rhino by submerging in sterile water for 30 seconds

▪ DO NOT use sodium chloride 0.9% and DO NOT apply lubricants which impair the CMC

fibres on the Rapid Rhino

▪ Insert into affected nostril parallel to the nasal septum floor

▪ If resistance is met on insertion, remove and reinsert in a position level with the hard

palate

▪ Insert until blue indicator ring is just inside the opening of the nostril

▪ Use 20mL syringe to insert air until the pilot cuff is firm but not hard

▪ If dual lumen, inflate the posterior lumen first, then the anterior lumen

▪ Recheck after 15-20 minutes as nasal swelling may have reduced, thus requiring the

balloon to be inflated more

▪ Tape the plastic butterfly to the patient’s cheek

▪ If epistaxis continues, pack the contralateral side

▪ Should be removed within 24-72 hours post insertion

o Merocel

▪ Position patient sitting head up, with head tilted forward

▪ Administer topical anaesthetic and vasoconstrictor

▪ Coat the tampon with antibiotic ointment (chloramphenicol) or lubricating jelly to

facilitate placement

▪ Insert the catheter by sliding it along the floor of the nasal cavity until the plastic

proximal fabric ring lies within the naris

▪ Large nares can be packed with two tampons (be sure to leave the tips of both exposed

for removal)

▪ Small nares can be packed with a paediatric tampon or an trimmed adult tampon

▪ Expand the tampon by infusing approximately 10 mL of saline

▪ If epistaxis continues, pack the contralateral side

▪ Should be removed within 24-72 hours post insertion





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• Posterior epistaxis

o Posterior packing is associated with higher rates of complications like pressure necrosis,

infection or hypoxia. Surgical intervention is markedly superior to packing

o Use a longer Rapid Rhine (as above)

o If not controlled, use a Foley catheter: -

▪ Apply topical anaesthetic and vasoconstrictor

▪ Lubricate the Foley catheter

▪ Insert the Foley catheter until the tip is visible in the oropharynx

▪ Partially inflate the balloon with ~5mL sterile water

▪ Pull the catheter until it rests against the posterior nasopharynx

▪ Inflate the balloon with an additional 5mL sterile water. Pain or distention of the soft

palate suggests overfilling

▪ Apply relatively firm tension

▪ Attach an umbilical clamp in front of the nasal, ensuring tension is maintained, to

prevent the catheter retracting. The clamp and nose should be padded to prevent nasal

soft tissue damage such as alar necrosis

▪ Pack the anterior nasal chamber with Merocel or a Rapid Rhino.

▪ If epistaxis continues, pack the contralateral nostril as above, using a Foleys catheter

and anterior packing

▪ Continual bleeding despite anterior and posterior nasal packing requires urgent ENT

intervention such as cauterisation, embolisation or arterial ligation

▪ Refer all patients with posterior epistaxis to the ENT team

Removal of packing in ED

• Should generally be performed by the ENT team, or with ENT support. If ENT unavailable, should only

be performed by ED doctors with training in this procedure

o Offer and administer analgesia as prescribed 30 minutes prior to procedure

o Explain procedure, obtain consent and reassure the patient

o Elevate head of bed (unless clinically contraindicated)

o Apply bolster to absorb any bleeding post removal of nasal packing





CONTROLLED DOCUMENT

• Rapid Rhino

o Attach 20mL syringe and gently remove air from balloon

o Leave Rapid Rhino in situ for 15 minutes

o Monitor for further signs of bleeding. Balloon can be reinflated if bleeding recommences

o Butterfly can be untaped from patient’s cheek and Rapid Rhino gently removed if no bleeding

observed

o Small amount of sterile water dripped into the nostril may help with removal

• Merocel

o Rehydrate with saline drops prior to removal for patient comfort

o Extract gently and slowly

o Monitor for further signs of bleeding

• Foleys catheter used for posterior epistaxis tamponade should only be removed by the ENT team, who

can manage complications or ongoing posterior epistaxis

Advice for patients being discharged Once there is cessation of epistaxis, observe the patient for 60 minutes prior to discharge. On discharge, advise the patient of the following and provide a written handout.

o Potential risks and complications related to the epistaxis episode, procedure or packing

o First aid treatment for further episodes and when to seek further medical advice

o Post procedure recovery timeline

o Not to remove any packing

o Avoid hot showers/ baths

o Avoid spicy foods, hot drinks, alcohol, or smoking

o Avoid strenuous exercise or lifting heavy objects

o Avoid bending over or straining. Bend at the knees if needed

o Keep bowel habits regular

o Avoid nose blowing or picking, encourage dabbing nose

o Sneeze/cough with mouth open

o Sleep with head raised 45 degrees

o Moisturise the mucosa by applying FESS Saline Nasal Spray, FESS Nasal Oil or Vaseline with a

cotton tip applicator

o Keep away from dusty environments, hot or dry heating, or large crowds as they contribute to

drying out and irritating the nasal mucosa

o Direct nasal sprays away from the septum

o Increase water intake

o Patients on anticoagulation presenting with minor epistaxis can generally continue or restart if

the INR levels are within the desired range

o NSAIDs should ideally be discontinued for three to four days unless contraindicated





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Special Circumstances Pandemic / COVID-19 Specific changes to the management for high-risk patients or during a pandemic include:

• Objective risk assessment and screening at triage for ILI symptoms

• PPE, including an appropriate face mask, eye protection and gown

• Advise the patient not to blow their nose

• Assessment of the patient in an isolation room or negative pressure room. Where aerosol generating

procedures are likely to occur, a negative pressure room is mandatory

• Assessment and management by an experienced clinician, and limiting the number of staff involved in

the patients care

• Early implementation of non-invasive interventions including bidigital compression to the lower third of

the nose for at least 15 minutes and administration of antifibrinolytic agents, such as tranexamic acid

• Avoiding atomised sprays including local anaesthetic / phenylephrine. Consider soaked pledgets instead

• If difficult to control, early packing

• A closed suction system with viral filters

• Avoidance of electrical cautery in ED

Pregnancy

• Epistaxis is a common problem during pregnancy, due to an increased nasal mucosal vascularity. The

prevalence in pregnant women is 20.3% compared with 6.2% in non-pregnant women

• Considerations

o Pregnant women will compensate during hypovolaemia, with reduced foetal perfusion. They

require early fluid or blood product resuscitation

o Aim for conservative measures first, including IV tranexamic acid or nasal packing

o If conservative treatment fails, involve ENT

o In general, delivery or foetal death causes immediate cessation of the epistaxis as underlying

factors, such as congestion and hyperaemia, disappear

Paediatric patients

• Epistaxis is rare in children younger than two years (~ 1 per 10,000) and should prompt

examination for signs of trauma (including NAI) or serious illness (ITP, HHT, etc). Any child with

recurrent epistaxis also needs careful examination

• Important signs alongside epistaxis include: -

▪ Petechiae, bruising, gingival bleeding (ITP, bleeding disorders)

▪ Mucocutaneous telangiectasias, hemangiomas (HHT)

▪ Enlarged lymph nodes, organomegaly, petechiae, pallor (haematological disease or

malignancy)

▪ Atypical bruising, oral or genital injuries, burns (NAI)





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▪ Fever, travel history, hepatomegaly (dengue or other viral illnesses)

▪ Unilateral bloodstained nasal discharge (nasal foreign body)

▪ Black unilateral nasal discharge (nasal button battery)

▪ Progressively worsening nasal obstruction with mucopurulent drainage and facial pain

(nasopharyngeal tumour). Additional symptoms can include hearing loss, torticollis,

trismus, unilateral cervical adenopathy, retrobulbar or ear pain, and neck pain

• The phenylephrine dose should not exceed 20 mcg/kg. It can be applied using a squirt bottle or a

small piece of cotton/gauze pledget gently placed in the nose

• If nasal packing is required, refer to ENT. Packing is contraindicated in infants younger than one

year of age due to the risk of aspiration and airway obstruction

Specific Conditions

• Haemophilia

o Identify type (A = factor VIII deficiency, B = factor IX deficiency), disease severity (baseline factor

activity levels), and whether an inhibitor is present. Mild cases may require desmopressin

(DDAVP). Severe haemophilia may require factor concentrates

• Von Willebrands disease (VWD)

o Options for therapy include desmopressin (DDAVP), Von Willebrands factor concentrates,

Factor VIII concentrates or platelet transfusions

• Significant thrombocytopenia or platelet function disorders

o Consider platelet transfusions, intravenous immune globulin (for ITP) or glucocorticoids

• Anticoagulated patients

o The decision to stop and/or reverse anticoagulation must balance the risk of thrombosis with

complications from bleeding

o Warfarin can be reversed using standard reversal agents

o DOACs are more difficult to reverse. If reversal is decided on, should be discussed with the on-

call haematologist

• Hereditary Haemorrhagic Telangiectasia (HHT)

o Epistaxis may be the presenting finding in a child with HHT

o Involve ENT

o Consider tranexamic acid, bevacizumab

• Juvenile Nasopharyngeal Angiofibroma

o Involve ENT

o Requires surgical management, radiotherapy or embolization





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Referral Guidance

• ENT Registrar is available for advice, patient review and procedural assistance Monday to Friday 8am to

5pm. Contact via JHC switchboard

• Prof. Peter Friedland (ENT) is also available during office hours on 0412137858 for advice (leave

message or send text message if not immediately available)

• Out of hours and on weekends, discuss with, or refer to the ENT registrar at SCGH. Contact via SCGH

switch (6457 3333). In rare cases, the JHC ENT Registrar may be available on Saturday mornings for

patient reviews

REFERENCES

1) Joondalup Health Campus SOP ED27: Epistaxis

2) Fiona Stanley Hospital (Frematle Group) Epistaxis Policy

3) Up To Date: https://www.uptodate.com/

4) Ayesha Tabassom et al, Epistaxis (Nose Bleed); StatPearls, Treasure Island Publishing, NCBI Bookshelf,

2020 Jan

5) G. Meccariello et al, Management of idiopathic epistaxis in adults: what’s new?; Acta

Otorhinolaryngologica Italica, 2019, 39:211-219

6) Vittorio D’Aguanno, et al, Clinical Recommendations for Epistaxis Management During the COVID-19

Pandemic; Otolaryngology, Head and Neck Surgery 1-3, American Academy of Otolaryngology, Head

and Neck Surgery Foundation 2020

7) Maria Grazia Piccioni et al, Case Report Management of Severe Epistaxis during Pregnancy: A Case

Report and Review of the Literature; Case Reports in Obstetrics and Gynaecology, Volume 2019, Article

ID 5825309, 3 pages

8) Royal Childrens Hospital Melbourne Guidelines:

https://www.rch.org.au/clinicalguide/guideline_index/Epistaxis/

9) Perth Childrens Hospital Guidelines: https://pch.health.wa.gov.au/For-health-professionals/Emergency-

Department-Guidelines/Epistaxis

https://www.uptodate.com/

https://www.rch.org.au/clinicalguide/guideline_index/Epistaxis/

https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Epistaxis

https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Epistaxis





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Epistaxis

Initial primary assessment, observations and ED first aid measures*. Appropriate PPE

Clear clots and apply topical vasoconstrictor (co-phenylcaine,

oxymetazoline, xylocaine) or tranexamic acid. Compress 15 –

20 mins. Keep patient fasted

If epistaxis resolves, consider unilateral silver nitrate cautery

ensuring nasal mucosa has been anaesthetised. Observe for 60 mins. Discharge home with written advice, GP F/U and FESS nasal oil or spray

Ongoing Epistaxis Confirmed Anterior

Epistaxis

Posterior epistaxis or unable to identify

point of origin Ensure vasoconstriction and topical anaesthesia. Insert merocel or rapid rhino (lubricate pack, insert parallel to floor of nose, expand pack, and secure). Prescribe analgesia. NBM

If ongoing epistaxis, obtain senior assistance immediately. Ensure vasoconstriction and topical anaesthesia. Insert 7.5cm or 9cm

(posterior) rapid rhino. If persistent epistaxis, remove pack and new clots, insert a lubricated 12 - 14F Foley catheter, inflate, lodge against posterior choana and secure with padding.

Pack anteriorly with a merocel or rapid rhino

Epistaxis Adequately Controlled

Ongoing Epistaxis

Observe for 60 mins. If epistaxis ceased, discharge home or admit to EAU (consider haemodynamic status, co-morbidities, blood loss, social concerns, comfort level). Provide a script for FESS nasal spray/oil, and written advice. Review anticoagulation and/or antiplatelet therapy. Arrange for ENT (or ED) follow-up in 24 – 48 hrs for removal of pack

Refer for ENT inpatient review +/- admission. Review patient regularly for recurrence of

epistaxis and complications. Prescribe analgesia

Consider: -

• Involving a senior

• Bloods, X-match,

Cannula

• Fluid resuscitation

• Moving to resus

• Reversal of

anticoagulation

Reassess regularly

*ED First Aid Measures: - Sit patient forward

Head down Compress anterior nares for ~15 mins

Ice to bridge of nose and nape Reassure patient

Analgesia / anxiolytics as indicated Consider antihypertensives

Keep patient fasted

Consider Other Causes: - Haematological malignancies,

Clotting disorders, Local neoplasms,

Infections, Drugs, AVMs, etc

Establish side and site

(anterior or posterior) of

epistaxis

Pack contralateral side with merocel, rapid

rhino or foley catheter. Reverse

anticoagulation where appropriate. Arrange

urgent inpatient ENT review. Move to the

resuscitation area. Ensure IV access, bloods,

crossmatch and adequate resuscitation. NBM





CONTROLLED DOCUMENT

This section is for Quality Department use

AUTHORISATION

Prepared By Dr Priyesh Sura

Reviewed/Authorised By Professor Friedland (ENT) & Dr Yuresh Naidoo

VERSION CONTROL AND HISTORY

Version 0.01 (Draft)

Version 1.00 Next review due 13/07/2024

Documents

PROCEDURE TITLE: Management of Epistaxis in the ED