Epistaxis

Question 1

You are asked to review an 86-year-old woman on the cardiology ward who is suffering from epistaxis. How would you assess and manage her?

Answer 1

Impression
This woman is suffering epistaxis, likely in the setting of concurrent anticoagulation given they are a cardiology inpatient. Most commonly occur on anterior septum at Little’s area. Would want to rule out a septal haematoma, as this is a surgical emergency which requires immediate drainage.

Causes of epistaxis to consider/rule-out

• mucosal trauma
• bleeding disorder (coagulopathy, VWD, F5L, etc)
• neoplasia (nasal polyps)

Otherwise

• haematemesis masquerading
• haemoptysis masquerading

Goals:
- stop the bleeding before conducting thorough assessment

Question 2

Epistaxis - History

Answer 2

History

• sx: SOCRATES, site of bleeding, extent, how long for? how much?, recurrent vs single episode?, any trauma? volume? Do you feel like the blood is running down the back of the throat (for posterior bleeds)?
• life-long bleeding, mucosal vs deep muscular/intra-articular
• Risk: age, cold, dry, low humidity, recent URTI (increased mucosal friability), nose picking, hypertension, heart failure
• PMHx: hypertension
• Medications: anticoagulants, antiplatelet (DAPT)
• Substances: cocaine
• SNAP

Question 3

Epistaxis - Examination

Answer 3

Examination
- General appearance + vital signs
Start A to E assessment if appears unstable
- ENT examination: intra-nasal inspection - masses, ulceration, etc - check for septal haematoma
- haematological examination: hepatosplenomegaly, telangiectasia’s, purpura, eccymosis

Question 4

Epistaxis - Investigations

Answer 4

Investigations
- extensive investigations are not often required

• Bedside: vitals signs
• Bloods: FBC, coags, further Ix if suspicious of bleeding disorder, group + hold, LFTs, Haemaglobin
• Imaging: CT facial bone if neoplasia suspected

Question 5

Epistaxis - Management

Answer 5

Management
Anterior vs posterior nasal bleed
- anterior most common
- posterior can be significant bleeds
- consider ENT consult for management input

Definitive

• haemostat methods: nasal compression, tampon, packing soaked in TXA, rapid rhino’s
• nasal spray vasoconstrictors
• reversal of anticoagulation if appropriate
• cautery with silver nitrate (chemical cquatery)
• can also conduct electrical dithermy
• positioning, head forward over the body rather than back (to prevent aspiration of blood), pressure on the nasal septum for haemostasis
• discuss with cardiology as to whether cease anticoagulation