Download Stapelfeld

EPISTAXIS
Christina Stapelfeld
NU 870 Spring 2016
Diagnosis:
• Epistaxis is defined by bleeding from the
nose, either anteriorly or posteriorly.
• Diagnosis is made based on observation of
the patient with a nosebleed.
Pathology:
• Anterior Epistaxis: Bleeding from Little’s area, an anterior
portion of the nose. This area is where the Kiesselbach
plexus is located. It contains the majority of blood vessels
in the nose. Anterior bleeds are venous in nature; “oozing”
blood. Occurs 90% of the time.
• Posterior Epistaxis: Arterial in nature. Involves the
internal maxillary arteries. Characteristic of more forceful
bleeding. Occurs only 10% of the time.
Pathology cont.
Causes:
• Nasal Trauma: nose picking, forceful nose
blowing, foreign body
• Severe drying: rhinitis, low humidity, supplemental
oxygen
• Underlying conditions: hypertension, deviated
septum, atherosclerotic disease, cocaine or
alcohol abuse
HPI & PMH
Amount of blood, duration, frequency
ROS: Head, Eyes, Ears, Nose, Throat, &
Respiratory system for symptoms of distress
History of allergies? Hypertension?
Atherosclerosis? Previous episodes of
epistaxis? Easy bruising? Hematuria? Melena?
Heavy menses?
Medication, Surgical, & Family HX
Medications: anticoagulants? NSAIDS? Salicylates? To
rule out toxicity
Surgery: Ears? Nose? Throat? i.e. sinuses, nasal
deviation, tonsillectomy, and/or adenoids
Family Hx: Osler-Weber-Rendu syndrome- hereditary
syndrome which affects blood vessels throughout the
body causing unexplained bleeding
Hemophilia
Social History
• Alcohol and Drug Use
• Allergens
• Is living space humidified?
Physical Exam:
• The physical exam should include the head, eyes, ears,
nose, & throat- is there a patent airway?
• Respiratory system until the source of bleeding is
identified
• Skin for rash including petechia and bruising- internal
bleeding?
• Lymph nodes and surround tissues for anything
suggestive of a tumor or malignancy
Diagnostic Testing
• Patients who are suspected for bleeding
and who are taking anticoagulant
medications should have labs drawn for
protime and platelet count
• If this is a reoccurring issue, sinus imaging
should be ordered- typically ENT
• When a cause cannot be identified, genetic
testing as well as further testing for tumors
can be ordered through a specialist
Differentials
• Allergic Rhinitis
• Medication toxicity
• Cocaine use
• Osler-Weber- Rendu syndrome
• Foreign body
Red Flags
• Inability to stop bleeding
• Airway obstruction
• Signs of hypovolemic shock
• Multiple reoccurrences without a known cause
Treatment
• Direct pressure by compression of the nares for fifteen minutes with
the patient sitting and leaning forward
• Combination topical decongestant and antihistamine to stop the
bleeding- Afrin
• Cauterization with silver nitrate when the source of bleeding can be
identified
• Nasal Tamponade or anterior packing for no less that 5 days when
the source of bleeding cannot be identified
• NasalCEASE- Calcium Alginate product found OTC – causes
coagulation via platelet aggregation
Nasal Tamponade
Anterior Nasal Packing
NasalCEASE
Teaching
• Avoid exercise and straining for several days
• Avoid nasal trauma
• Moisturize nasal mucosa with water based
lubricants
• Humidify living space
• Nasal packing should be moisturized with saline
several times a day
• First aid and how to stop future nose bleeds
• When to seek medical attention
Referral, Follow-Up, & Outcome
• Immediate referral to ER for bleeding that cannot
be stopped or an active posterior bleed is
suspected.
• Recurrent or large bleeds should be referred to
an ENT for further testing
• Follow up with PCP in 2-4 weeks to assess for
recurrence and sooner if bleeding continues or
packing needs to be removed
• The desired outcome for epistaxis is to stop the
bleeding and treat the cause in recurring
situations
References:
• Barnes, M., Spielmann, P., & White, P. (2012).
Epistaxis: A Contemporary Evidence Based
Approach. Otolaryngologic Clinics of North America,
45(5), 1005-1017. Retrieved January 30, 2016.
• Goroll, A. H., & Mulley, A. G. (2014). Primary Care
Medicine (7th ed.). Philadelpia, PA: Wolters Kluwer
Health.
• Nguyen, Q. (2015, January 24). Epistaxis Treatment
& Management. Retrieved January 30, 2016, from
http://emedicine.medscape.com/article/863220treatment