Nose Bleeding (Epistaxis)

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Nose bleeding is a condition which is common in adults. It may be due to a local cause in the nasal  cavity (e.g. trauma, tumor, foreign body, septal varices, or septal deviation); or a systemic cause  (e.g.  blood  disorders,  vascular  disorders,  renal  failure,  hepatic  failure,  or  use  of  anticoagulants  (warfarin, heparin). 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
  • Put the patient in a sitting position and advise the patient to pinch the soft part of the nose gently for 5minutes
  • Put on a gown, glasses, head light and sterile gloves and evacuate clots. Do a thorough head and neck examination
  • Cauterize septal varisces (if any) using a silver nitrate pencil
  • 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)  or  special merocele pack, using a dissecting forcep (if bayonet forcep is not available)
  • Put rolled dry gauze on the collumela 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 collumela 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) 

B: azithromycin (PO) 500mg 2 hourly for 3days. Children: 10mg/kg 24hourly for 3days 

OR 

B: amoxicillin+ clavulanic acid (PO) Adults: 625mg 8hourly.  Children: 375mg 12hourly for 7days 

AND 

A: paracetamol (PO) 1gm 8hourly until fever is controlled Children 10 mg/kg body weight 8 hourly until fever is controlled 

AND 

A: ephedrine (0.5% and 1%) nasal drops, Adults and children above 12 years: Instill 1 to 2drops in each nostril, not more than 4times a day for 3-5days 

OR 

S:  xylometazoline  (0.05%  and  0.1%)  nasal  drops/spray.  Adults  and  children  above  6 years:  Instill  2  to  3drops  in  each  nostril  8hourly  for  3  to  5days  or  1  to  2sprays  in  each  nostril 8hourly for 3 to 5days

AND 

C: tranexamic acid (PO/IM) Adults: 500mg 8hourly for 5 to 8days. Children: 25mg/kg 6 or 8hourly for 5-8days 

AND 

C: Silver Nitrate Stick - Apply on the lesion once IF the bleeding area is identified. 

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

Surgical management 

  • Endoscopic electrical cauterization of the lesion for posterior nasal bleeding
  • Ligation/Clipping/cauterization of bleeding vessel (open or endoscopic)

Note:  Rule out systemic causes of epistaxis eg. renal, blood dyscrasias and liver failure