Epistaxis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief:Amir Behzad Bagheri, M.D. José Eduardo Riceto Loyola Junior, M.D.[2]
Overview
Most of the time no action is needed to stop epistaxis. In active bleeding, nasal compression is the first line strategy to stop bleeding. If bleeding continues there are other options such as cautery and vasoconstrictive agents such as oxymetazoline or phenylephrine to control bleeding.
Medical Therapy
If nasal bleeding is active and nasal compression cannot stop the bleeding, there are the following medical options:[1] [2] [3] [4] [5]
- General management of patients is important. Stabilizing the patient and treating the specific cause is the basis of management.
- At first airway, breathing and circulation should be evaluated.
An algorithm for the management of epistaxis is depicted below:[6]
| Epistaxis Treatment by a primary care physician or emergency physician | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ❑ Compression of the nostrils ❑ Ice application to the neck area ❑ Upright sitting position ❑ Blood to be spat out ❑ Take blood pressure, lower if appropriate | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Patient hemodinamically stable, bleeding stops | Patient hemodinamically unstable | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Patient hemodinamically stable, bleeding persists | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ❑ 30min observation, ❑ Antiseptic nasal cream | ❑ Emergency transfer to ENT department ❑ Volume replacement | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Bleeding stops: ❑ Discharge patient home ❑ Prevent recurrence; ❑ Nasal mucosal care ❑ No nose-blowing for 7-10 days | Bleeding resumes | Emergency referral to otorhinolaryngologist | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Anterior rhinoscopy Endoscopy if required | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Source of bleeding visible, anterior | Source of bleeding not visible and/or posterior | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Bleeding stops: ❑ Discharge patient home ❑ Prevent recurrence; ❑ Nasal mucosal care ❑ No nose-blowing for 7-10 days | Eletrocoagulation or silver nitrate cautery; Hemostatic gauze if required | Bleeding persists: Nasal packing | Nasal packing | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Treatment of epistaxis in the ENT department | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Bleeding stops | Bleeding persists, patient fit for surgery | Bleeding persists, patient not fit for surgery | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Remove packing after 48h, antibiotics if needed | Surgical treatment, usually endoscopic sphenopalatine ligation | Embolization | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| If bleeding persists, embolization | If bleeding persists: Patient fit for surgery - surgery Patient not fit for surgery - embolization | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Medical Therapy:
- Vasoconstrictors (Use with caution in children and patients with glaucoma, HTN, peripheral vasoconstriction, cardiac diseases and cerebrovascular problems):
- Preferred regimen (1): Oxymetazoline 0.05% intranasal spray. In children <6 years just with physicians suggestion.
- Alternative regimen (1): Phenylephrine 0.25% intranasal spray. In children ≥2 years Phenylephrine 0.125% nasal solution can be used.
- Alternative regimen (2): Epinephrine 1:100,000 with Lidocaine 1% (Topical ).
- Antifibrinolytic:
- Preferred regimen (1): Tranexamic acid (TXA) (Topical ). In coagulopathy and HHT patients is preferred.
- Preferred regimen (1): Tranexamic acid (TXA) (Topical ). In coagulopathy and HHT patients is preferred.
- Chemical cauterization (At first anesthesia bleeding site and limit nasal cautery to site:
- Preferred regimen (1): Silver nitrate 25%-75%
- Alternative regimen (1): Chromic acid
- Alternative regimen (2): Trichloroacetic acid
References
- ↑ Tunkel, David E.; Anne, Samantha; Payne, Spencer C.; Ishman, Stacey L.; Rosenfeld, Richard M.; Abramson, Peter J.; Alikhaani, Jacqueline D.; Benoit, Margo McKenna; Bercovitz, Rachel S.; Brown, Michael D.; Chernobilsky, Boris; Feldstein, David A.; Hackell, Jesse M.; Holbrook, Eric H.; Holdsworth, Sarah M.; Lin, Kenneth W.; Lind, Meredith Merz; Poetker, David M.; Riley, Charles A.; Schneider, John S.; Seidman, Michael D.; Vadlamudi, Venu; Valdez, Tulio A.; Nnacheta, Lorraine C.; Monjur, Taskin M. (2020). "Clinical Practice Guideline: Nosebleed (Epistaxis)". Otolaryngology–Head and Neck Surgery. 162 (1_suppl): S1–S38. doi:10.1177/0194599819890327. ISSN 0194-5998.
- ↑ Krempl, Greg A.; Noorily, Allen D. (2016). "Use of Oxymetazoline in the Management of Epistaxis". Annals of Otology, Rhinology & Laryngology. 104 (9): 704–706. doi:10.1177/000348949510400906. ISSN 0003-4894.
- ↑ Montastruc, François; Montastruc, Guillaume; Taudou, Marie-Josée; Olivier-Abbal, Pascale; Montastruc, Jean-Louis; Bondon-Guitton, Emmanuelle (2014). "Acute Coronary Syndrome After Nasal Spray of Oxymetazoline". Chest. 146 (6): e214–e215. doi:10.1378/chest.14-1873. ISSN 0012-3692.
- ↑ Krulewitz, Neil Alexander; Fix, Megan Leigh (2019). "Epistaxis". Emergency Medicine Clinics of North America. 37 (1): 29–39. doi:10.1016/j.emc.2018.09.005. ISSN 0733-8627.
- ↑ Douglas, Richard; Wormald, Peter-John (2007). "Update on epistaxis". Current Opinion in Otolaryngology & Head and Neck Surgery. 15 (3): 180–183. doi:10.1097/MOO.0b013e32814b06ed. ISSN 1068-9508.
- ↑ Beck R, Sorge M, Schneider A, Dietz A (2018). "Current Approaches to Epistaxis Treatment in Primary and Secondary Care". Dtsch Arztebl Int. 115 (1–02): 12–22. doi:10.3238/arztebl.2018.0012. PMC 5778404. PMID 29345234.