Written by: Peter Serina, MD, MPH (NUEM ‘22) Edited by: Danielle Miller, MD (NUEM ‘19) Expert Commentary by: Seth Trueger, MD, MPH
Expert Commentary
Great overview by Dr. Serina and Dr. Miller of this core EM topic. Epistaxis is in many ways an archetype of the EM problem: it happens to nearly everyone at some point in their lives; most people do fine (and don’t ever need to seek care); most who seek care need a little attention but not much intervention; a small fraction account for most of the work but still generally do well with management; and a tiny fraction of a percent need consultants, may be horribly sick or need rare procedures. There are a lot of potential ways to manage epistaxis (especially those that are only a bit difficult to control) and I find it helpful to distill into fewer options so that things don’t get drawn out.
Much like dysrhythmias, step 1 is stable vs unstable and if they are going to need ENT/IR/airway management, the rest is a waste and don’t dawdle to delay definitive treatment. This is very rare, and most patients go into a stable, stepwise approach:
1) Pinchers
I find most patients either resolved by the time we see them, or simply need some basic nasal pinching. Either way, I use this as an opportunity to counsel patients and *actually demonstrate* what to do if this happens again at home. That includes me pinching their nose in the right place with the right amount of force, and explaining each step so that they understand the rationale (eg blow your nose to get rid of mucus and clots so there are clean surfaces; tilt your head forward so blood doesn’t trickle down your throat and make you release your pinching). I also always put these instructions in their DC paperwork:
If your nose starts to bleed:
BLOW YOUR NOSE: this sounds backwards but it will clear out any clot or mucus that will stop a proper clot from forming
PINCH YOUR NOSTRILS TOGETHER: hold the soft part of your nose together (just below the bony bridge)
DO NOT LET GO FOR 20-30 MINUTES: not even for a second. Do not switch hands. Do not check to see if it's working. Watch an entire TV show on your phone while pinching your nose.
TILT YOUR HEAD FORWARD: this will stop blood from running down your throat and making you feel miserable
Things you can do to prevent nosebleeds:
Keep all foreign bodies out of the nose. This includes fingertips and tissue paper -- do not put anything up your nose
Use a humidifier at home to help keep your nose skin moist
Return to the ER if you have any concerning symptoms including:
bleeding that won't stop after 30 minutes of continuous pressure
weakness
dizziness
any other new or concerning symptoms
2) Packers
This is where there is a lot of leeway. If there is something obvious for me to cauterize, I will use some silver nitrate. If I think there is a reasonable chance of success, I will try temporary packing with a TXA-soaked pledget for 10 minutes. If I don’t think that will work, or if that fails, I go straight to a rhinorocket which I also soak in TXA (instead of water); I haven’t seen data for this but it is cheap and safe so why not?
3) Phone calls
If packing fails, ENT consult. Not fun and can take some time (and usually ends up with a recommendation for amox/clav that probably isn’t necessary) but fortunately is rare.
Seth Trueger, MD, MPH
Assistant Professor of Emergency Medicine
Department of Emergency Medicine
Northwestern University
How To Cite This Post:
[Peer-Reviewed, Web Publication] Serina, P. Miller, D. (2020, Aug 17). Epistaxis Management [NUEM Blog. Expert Commentary by Treuger, S]. Retrieved from http://www.nuemblog.com/blog/epistaxis-management.
