Nose Bleeding (Epistaxis)

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It is a condition that involve bleeding through the nose.

Causes

  • It may be due to a local cause in the nasal cavity (e.g. trauma, tumour, foreign body, septal varices, or septal deviation);
  • Systemic cause (e.g. blood disorders, vascular disorders, renal failure, hepatic failure, or use of anticoagulants (warfarin, heparin)
  • (Usually 90% from a plexus of veins in Little's areas) due to nose−picking, trauma (fall in games, assault, etc,)
  • Nasal and paranasal neoplasms.
  • Nasal infection
  • Systemic derangements e.g. acute fevers, disease with uraemia,
  • Abnormalities of blood clotting, foreign bodies in the nose.

Management

  • Most cases of epistaxis are minor; do not require hospitalization. Patients with significant nose bleeding do require hospitalization.

Non-pharmacological treatment

  • Stabilize the patient: put an open intravenous line, do blood grouping and cross matching the patient in a sitting position and advise the patient to pinch the soft part of the nose gently for 5 minutes.
  • Put on a gown, glasses, head light and sterile gloves and evacuate clots. Do a thorough head and neck examination.
  • Cauterize septal varices (if any) using a silverex stick
  • Do an anterior nasal packing by introducing into the nasal cavity as far posterior as possible sterile Vaseline gauzes (or iodine-soaked gauzes if not available) using dissecting forceps (if bayonet forceps is not available).
  • Put rolled dry gauze on the columella and plaster it.

If the patient is still bleeding

  • Do a posterior nasal packing using a Foley’s catheter introduced through the nasal cavity into the oropharynx, balloon it with normal saline up to 10–15cc while pulling it outward to impinge on the posterior nasal choana, then do anterior nasal packing as above.
  • Put dry gauze on the nose to prevent necrosis of the columella and fix the catheter on the nose with an umbilical clamp.
  • Almost all of the nasal bleedings will be controlled by this way.

Note: Remove the packs after 72 hours

Pharmacological treatment (to prevent rhinosinusitis)

Phenoxymethylpenicillin oral

Adult:

500mg every 8 hours for 7 days.

Child:

up to 5 years: 6 mg/kg every 6 hours for 10 days

OR

Azithromycin oral

Adult:

500mg once daily for 3 days.

Child:

10mg/kg once daily for 3 days

OR

Amoxicillin 500mg/clavulanic acid 125mg oral

Adult:

One tablet every 8 hours for 7 days

Child:

Amoxicillin 250mg/clavulanic acid 125mg) every 12 hours for 7 days

PLUS

Paracetamol oral until fever is controlled

Adult:

1gm every 8 hours

Child:

10 mg/kg body weight every 8 hours

Note: Putting an ice cube on the forehead, extending the neck or placing a cotton bud soaked with adrenaline in the vestibule will not help.

Referral

  • Refer the patient to the next facility with adequate expertise and facilities if:
  • The patient is still bleeding repack and refer immediately, Failure to manage the underlying cause, refer the patient.