Epistaxis

Epistaxis is defined as hemorrhaging arising from the nostrils, nasal cavity, and/or nasopharynx. It is a common presenting complaint to the Emergency Department, due to a lack of proper management knowledge in the community. Though most cases are fairly benign and usually self-resolve, a small percentage can present in major hemorrhaging which can be life threatening if not controlled.

Classifications & Anatomy
Epistaxis is classified into two categories, delineated by affected anatomical regions.

Anterior epistaxis is defined as hemorrhage arising from the anterior portion of the nasopharynx (Little's area), which is supplied by the venous and capillary circulation of the Kiesselbach plexus. Anterior hemorrhages account for around 90% of bleeds that present to hospital, and often present as slower bleeds which may continue oozing if pressure is not applied appropriately.

Posterior epistaxis is defined as a bleed arising from the posterior nasopharynx, often from an arterial source. The most common sources for posterior bleeding arise from the branches of the sphenopalantine artery. These bleeds pose increased risk due to 1) difficulty in tamponading the source and 2) potential for airway obstruction and aspiration.

Risk Factors
Generally, the large majority of anterior nosebleeds stem from local causes, such as dry, irritated nasal mucosa, which is a common phenomenon in drier climates/seasons.

Other etiologies that may complicate epistaxis presentations: * Despite conventional teaching, there is very little evidence to suggest that essential hypertension causes epistaxis. That being said, hypertensive emergencies/crises can present with multiorgan system failure, including DIC, which could present as epistaxis.
 * Trauma/mechanism of injury
 * Anticoagulation
 * Bleeding risk factors (blood dyscrasias, thrombophilias)
 * History of nasopharyngeal tumours
 * Foreign bodies
 * Idiopathic or iatrogenic (eg. oxygen nasal cannulas)

Workup & Treatment
As always, on assessing a patient who is actively hemorrhaging, the first objective is always to ensure hemodynamic stability, and ensure that there is no impending respiratory compromise.

The history should include a brief summary of: During the physical exam, examination of the nostrils and nasal cavities with a nasal speculum is warranted. However, given the difficulties in visualizing the nasal cavities during an active hemorrhage, it is usually preferable to attempt interventions first to tamponade or slow the bleeding (such as nasal clips). Once the bleeding is temporized or slowed, it is much easier to visualize the anterior portions of the nasal cavities to determine the site of bleeding.
 * Laterality (left vs right nostril, vs bilateral)
 * Duration of the current bleed
 * Frequency of the bleed, constant vs intermittent
 * Estimated blood loss and severity of the bleed
 * Previous methods attempted to stop the bleed and duration
 * Inciting trauma/incident
 * Past medical history, current medications (especially antiplatelet meds or anticoagulation)
 * Family history of blood dyscrasias

* Any evidence of gushing, bright red blood on exam should trigger suspicion for posterior bleeding, and urgent consultation with ENT is recommended.

For the majority of simple presentations, no further workup is required. Patients presenting with epistaxis on anticoagulation should have a CBC, INR, aPTT and type & screen done (as there is fair potential for large amounts of blood loss).

A general treatment approach should consist of the following steps: In any difficult anterior packing, there must be a consideration for Toxic Shock syndrome, which happens in 16 out of every 100,000 packings. Although there exists no evidence supporting the use of prophylactic antibiotics post anterior packing, it should be a serious consideration in patients who are more susceptible to infections (immunocompromised). A good choice of antibiotic is amoxicillin-clavulanate to cover for any sinusoidal infection.
 * 1) Consistent pressure on the flesh of the nose to attempt to tamponade an anterior cavity bleed (may be assisted with nasal clips). This pressure should be held for minimum 15 minutes.
 * 2) Anterior packing can be attempted with several methods:
 * 3) Nasal tampon packing (eg. Merocel) inserted into the affected nostril(s)
 * 4) * This may be pretreated with topical vasoconstrictors or lidocaine
 * 5) * The tampon is covered in bacitracin ointment to facilitate insertion
 * 6) * Following insertion, infiltrate the merocel with normal saline to expand and tamponade.
 * 7) Packing gauze soaked with petrolatum, and inserted with the guidance of a nasal speculum until the anterior cavity is packed and the bleeding is tamponaded.
 * 8) Foley ballooning - using a inflatable ballooning device, such as a Foley catheter, to apply tamponading pressure onto the affected chamber.
 * 9) There are specialized thrombophilic gels that certain hospitals may carry. Please check with your local ENT specialist/pharmacy formulary prior to using these.
 * 10) Cautery
 * 11) This should only be applied if a source is visualized for an anterior bleed, and only if the practioner is comfortable in this technique.
 * 12) Chemical cautery is often performed with silver nitrate sticks, applied for <10 seconds until a white precipitant forms.
 * 13) Cautery requires some form of local anesthetic beforehand, often with lidocaine combined with a local vasoconstrictor.
 * 14) Risks with cautery are perforation of the nasal septum, ulceration and infection.

Trauma & other considerations
Patients that present with epistaxis post-trauma may require further imaging after the bleeding is tamponaded. Indications for further imaging, such as a facial bones CT scan or a full CT head, include a dangerous mechanism of injury, signs of basal skull fracture, palpable crepitus along the cheeks/jawline, signs of orbital fracture (hematoma, point tenderness or crepitus around the orbits).

Any patient presenting with a major epistaxis who is on oral anticoagulation should be reversed as soon as possible. If the patient is taking warfarin, octaplex and vitamin K should be administered in an actively bleeding patient (provided that the initial conservative management does not work to halt the bleeding). In a patient who is on a novel oral anticoagulant, consultation with a hematologist for use of FEIBA as a reversal agent should be considered.

Patients that present with chronic recurrent bleeds, with no obvious triggers should be worked up for thrombophilias and blood dyscrasias if appropriate given clinical context (family history).