A 25-year-old woman presents with a nosebleed that started after blowing her nose 30 minutes ago. She is currently catching the drips in a bowl and you have been asked to see her urgently by the triage nurse. Her observations are normal, and she has no haemodynamic compromise.

1. How should this patient be managed initially?
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The initial assessment of a patient with epistaxis, even if bleeding appears to have stopped, should be with a standard ABC assessment concentrating on the airway and haemodynamic status.

If active bleeding is still apparent and there is evidence of haemodynamic compromise, then both resuscitative and first aid measures should be started immediately.

Epistaxis should be treated as a circulatory emergency depending on the severity especially in the elderly, patients with clotting disorders or bleeding tendency and those on anticoagulants. Intravenous access should be inserted using a minimum of an 18-gauge (green) cannula and blood should be sent including FBC, U&Es, clotting and group and save (depending on blood loss) in these patients. Patients should be allocated to majors or an area where they can be closely observed as sometimes dislodgement of blood clot can lead to catastrophic bleeding.

First aid measures to control bleeding should include the following:

  • The patient should be sat upright with their body tilted forward and their mouth open. They should avoid lying down, unless they are feeling faint or there is evidence of haemodynamic compromise. Leaning forward reduces he passage of blood into the nasopharynx.
  • The patient should be encouraged to spit out any blood passing into the throat and advised not to swallow it.
  • The soft, cartilaginous part of the nose should be pinched firmly, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
  • If the patient is unable to comply, then an alternative technique is to ask a relative or staff member or apply an external pressure device such as a swimmer’s nose clip.

 

A common misconception is that compression of the bones will help to stop the bleeding, and this should be dispelled. Application of ice to the neck or forehead has not been shown to influence nasal blood flow. Sucking on an ice cube, however, has been shown to reduce nasal blood flow, and applying an ice pack ice directly to the nose may also help.

2. If the bleeding stops after your initial management, which medication should be prescribed?
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If bleeding stops with first aid measures the application of a topical antiseptic preparation to reduce crusting and vestibulitis should be considered. Naseptin (chlorhexidine and neomycin) cream is commonly used and should be applied to the nostrils four times daily for 10 days. If compliance is a problem, advise that it can be used twice daily for up to 2 weeks. If the patient is allergic to neomycin, peanut, or soya, Naseptin cream should not be prescribed. A suitable alternative is mupirocin nasal ointment, which should be applied to the nostrils two to three times a day for 5–7 days.

3. If the bleeding does not stop after your initial management, how should you proceed?
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If bleeding does not stop after 10-15 minutes of nasal pressure, then either nasal cautery or nasal packing should be carried out. Nasal cautery is suitable if the bleeding point can be identified and the procedure can be tolerated (e.g., in older adults, but not younger children).

If nasal cautery is ineffective, the bleeding point cannot be identified, or there is bilateral bleeding, then the nose should be packed. Traditional ribbon gauze soaked in bismuth iodoform paraffin paste (BIPP) packing has now been superseded by the development of nasal tampons. There are two main types of tampon, the compressed sponge (e.g. Merocel, Rhino Rocket) type, and the inflatable balloon tampon (e.g. Rapid Rhino).

 

Further reading:

NICE clinical knowledge summary on the management of epistaxis

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