presented by Dr. Ramona Vanel
I remember in my third grade current events our weekly assignment was to tackle the who, what, when, where and why’s of the events. Today we will discuss the WHO, WHAT, WHEN, WHERE, WHY of nose bleeds!
WHO
The epidemiology of nosebleeds seems to be in a bimodal distribution:
school aged children and middle aged men.
WHAT
What are nosebleeds … seriously?! Ok, this seems intuitive but there is more to this question than meets the eye. We will discuss that more a bit later in this post.
WHEN
Most often this occurs during the winter season.
WHERE
This is a GREAT QUESTION. There is a difference between ANTERIOR nosebleeds and POSTERIOR nosebleed; with the majority being anterior nose bleeds.
WHY
This requires taking a very good history. Ask about a history of bleeding disorders such as von Willebrand, history of ITP/ HHT, history of taking blood thinners, nose picking, a recent URI, trauma, etc.
Nosebleeds are quite common to see in the ED. It is imperative that the ED physician will know how to tackle cases of both anterior and posterior nosebleeds.
Anterior nosebleeds mainly arise from the sphenopalatine artery. There is a great network of vessels that form a rich vascular network called the Kiesselbach’s plexus.
With posterior nosebleeds there is another rich network of arteries in the posterior nasal cavity. The bleeding that occurs from posterior nosebleeds are from the posterior ethmoid arteries. Keep in mind that most bleeds are anterior.
I have my own way of tackling nosebleeds, and I am sure every ED physician will have their own style to addressing it themselves.
Keep in mind the ABC’s. Make sure their airway is intact, especially with posterior nosebleeds. Check the blood pressure!
You may want to consider testing H/H and coagulation studies based on history of HHT/ ITP, history of plavix, aspirin, or coumadin use. You may want to consider imaging with a history of trauma.
Start by having an ENT kit handy which includes suction and a RapidRhino. I look at the unaffected nare make sure I can clearly identify the nasal septum (remember that bleeds can be bilateral). Remove any clots that may be visible or ask patient to blow their nose. Then, tell the patient to HOLD PRESSURE to the nose externally in the sniffing position for about 15 min. (The above image is a nice trick to keep in your back pocket to help your patients hold pressure .)
After 15 minutes, recheck to see if the bleeding has stopped. If not, then reach for your RapidRhino. Some individuals will coat their RapidRhino with bacitracin which is not only an excellent idea, but also the recommended method. This is of course to prevent infection and possible TSS (Toxic Shock Syndrome). Normally the RapidRhino is successful, without the need for further intervention.
In the event the RhapidRhino is not successful, you may choose to cauterize the bleed. It is important to visualize the bleeding vessel for cauterization. Silver nitrate is great for cauterization. Please be mindful not to perforate through the nasal septum, especially when dealing with bilateral nasal bleeds.
Patient may follow up with ENT within 1-2 days after RapidRhino is placed. There is no general consensus if antibiotics are needed for prevention of Toxic Shock Syndrome.
Posterior nosebleeds maybe be a bit more aggressive and continue to bleed regardless of nasal packing. In the event of posterior nosebleeds, one can insert a foley to tamponade the bleeding. JUST REMEMBER THE AIRWAY. All patients who receive posterior packing with either an intranasal sponge or a foley will need an ENT consult and likely admission. After foley insertion, patient will need to be monitored in the intensive care unit.
Remember, most nosebleeds are not critical and Remember your ABCs.
Reference
Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011.
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