Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis may be treated with digital compression by applying firm sustained compression of the lower one third of the nose for 15 full minutes. Pressure can be applied by the treating clinician or by patients and caregivers under the direction of the clinician. An alternative to digital compression is the use of a commercial nose clip, if available. Applying local vasoconstrictors to the nasal cavity can be a useful adjunct to digital nasal compression.
If pinching is unsuccessful and the bleeding site is accessible and can be localized on anterior rhinoscopy, the next step is to control anterior epistaxis using cautery, which avoids some disadvantages of nasal packing How To Treat Anterior Epistaxis With Nasal Packing Anterior epistaxis (nasal hemorrhage) can often be controlled by nasal packing of the involved area. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis... read more (eg, discomfort, risk of infection, migration of packing material).
If bleeding continues from an unidentified anterior site despite use of nasal compression and cautery, nasal packing How To Treat Anterior Epistaxis With Nasal Packing Anterior epistaxis (nasal hemorrhage) can often be controlled by nasal packing of the involved area. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis... read more is required.
If bleeding is seen in the posterior pharynx but not in the anterior nasal passage, a posterior epistaxis should be considered. Posterior epistaxis How To Treat Posterior Epistaxis With a Balloon Posterior epistaxis (nasal hemorrhage) can often be controlled with balloon tamponade. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior bleeding is much... read more is managed differently from anterior epistaxis, so identifying the site of bleeding is important whenever possible.
(See also Epistaxis Epistaxis Epistaxis is nose bleeding. Bleeding can range from a trickle to a strong flow, and the consequences can range from a minor annoyance to life-threatening hemorrhage. Most nasal bleeding is anterior... read more and Clinical Practice Guideline: Nosebleed [Epistaxis].)
Indications for Treating Anterior Epistaxis With Cautery
Anterior nasal bleeding from a clearly visible site
Failure of nasal compression to stop nasal bleeding
Anterior bleeding sites are usually apparent on direct examination. If no site is apparent and there have been only 1 or 2 minor nosebleeds, no further examination is needed. If bleeding is continuing or recurrent and no site is seen, it may be necessary to use an anterior nasal packing How To Treat Anterior Epistaxis With Nasal Packing Anterior epistaxis (nasal hemorrhage) can often be controlled by nasal packing of the involved area. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis... read more method.
Contraindications to Treating Anterior Epistaxis With Cautery
Inability to see the source of bleeding
Procedures described here are intended for epistaxis that is spontaneous or resulting from minor trauma. Epistaxis in patients with significant facial trauma should be managed by a specialist.
Patients with a pacemaker and/or defibrillator may require cardiology consultation before doing monopolar electrocauterization.
Patients with a cochlear implant may not be able to undergo monopolar electrocauterization.
Complications of Treating Anterior Epistaxis With Cautery
Injury or perforation of the nasal septum, particularly from multiple, overly aggressive or bilateral attempts at cauterization
Equipment for Treating Anterior Epistaxis With Cautery
Gloves, mask, and gown
Gown or drapes for patient
Suction source and Frazier-tip and/or other suction-tip suction catheters
Sterile gauze sponges
Chair with headrest or an ear, nose, and throat (ENT) specialist's chair
Light source and head mirror or headlamp with adjustable narrow beam
Frazier-tip suction catheter
Silver nitrate sticks or electrocautery
Antibiotic ointment (eg, bacitracin)
Topical anesthetic/vasoconstrictor mixture (eg, 4% cocaine, 1% tetracaine, or 4% lidocaine plus 0.5% oxymetazoline) or topical vasoconstrictor alone (eg, 0.5% oxymetazoline spray)
Cotton swabs or pledgets
Additional Considerations for Treating Anterior Epistaxis With Cautery
Ask about use of anticoagulant or antiplatelet drugs.
Check complete blood count (CBC), prothrombin time (PT), and partial thromboplastin time (PTT) if there are symptoms or signs of a bleeding disorder or the patient has severe or recurrent epistaxis.
Relevant Anatomy for Treating Anterior Epistaxis With Cautery
Kiesselbach's plexus is a vascular watershed area on the anterior nasal septum that is the most common site of anterior epistaxis.
Positioning for Treating Anterior Epistaxis With Cautery
The patient should sit upright in the sniffing position with the head extended, preferably in an ENT specialist's chair. The patient's occiput should be supported to prevent sudden backward movement. The patient's nose should ideally be level with the physician's eyes.
The patient should hold the emesis basin to collect any continued bleeding or emesis (eg, of swallowed blood).
Step-by-Step Description of Treating Anterior Epistaxis With Cautery
Have the patient gently blow the nose to remove clots, or suction the nasal passageway carefully.
Insert a nasal speculum with your index finger resting against the patient's nose and the handle parallel to the floor (so the blades open vertically).
Slowly open the speculum and examine the nose using a bright headlamp or head mirror, leaving one hand free to manipulate suction or an instrument.
Use a Frazier-tip suction catheter to remove any blood and clots obscuring the view.
Look for blood flowing from the anterior septum in the area of Kiesselbach's plexus, and look for blood flowing from the back of the nose.
Apply a topical vasoconstrictor/anesthetic mixture: Place about 3 mL of 4% cocaine solution or 4% lidocaine with oxymetazoline in a small medicine cup and soak 2 or 3 cotton pledgets with the solution and insert them into the nose, stacked vertically (or spray in a topical vasoconstrictor such as oxymetazoline and place pledgets containing only topical anesthetic).
Leave the topical drugs in place for 10 to 15 minutes to stop or reduce the bleeding, provide anesthesia, and reduce mucosal swelling.
Use silver nitrate sticks to cauterize the site only if vasoconstriction has stopped the bleeding and the bleeding site is clearly visible. Place the tip of the silver nitrate stick against the site and roll the tip over the bleeding site for 4 to 5 seconds until an eschar forms. This will turn the mucosa a grayish color.
Wipe or suction away any excess silver nitrate to avoid any further cautery at this site or other sites in the nose.
Patients often sneeze after silver nitrate cautery, which may restart bleeding (and splatter the operator with blood), necessitating repeat cautery.
If using electrocautery, place the tip of the instrument on the area of bleeding mucosa and apply coagulation current for a few seconds until charred mucosa is visible. If using thermal cautery, place the heated tip of the device on the area of bleeding for several seconds until the mucosa is charred. Protracted duration of cautery, application of cautery over a wide area, or bilateral use of cautery on the nasal septum can result in tissue injury including septal necrosis with resultant perforation. Other risks include infection and scarring.
If cautery has not stopped the bleeding after 2 attempts, another technique, such as a nasal packing How To Treat Anterior Epistaxis With Nasal Packing Anterior epistaxis (nasal hemorrhage) can often be controlled by nasal packing of the involved area. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis... read more , should be used.
After hemostasis is successful, apply antibiotic ointment (such as bacitracin) to the cauterized area.
Aftercare for Treating Anterior Epistaxis With Cautery
Advise the patient not to use aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 days after treatment of epistaxis.
The cauterized area should be coated with petroleum jelly 2 to 3 times a day for 3 to 5 days.
Advise the patient that if bleeding recurs, the nostrils should be pinched closed for 20 minutes without interruption. Applying oxymetazoline nasal spray before pinching the nostrils may help control bleeding. If this does not stop the bleeding or if the bleeding is profuse, the patient should return to the emergency department.
Warnings and Common Errors When Treating Anterior Epistaxis With Cautery
Do not open the nasal speculum laterally or use the nasal speculum in an unsupported manner. (Brace a finger of the hand holding the speculum on the patient's cheek or nose.)
Avoid burning the mucous membrane too deeply. Cautery with silver nitrate is less likely to burn too deeply and is preferred to electrocautery.
Do not cauterize the nasal septum bilaterally because doing so increases the risk of septal injury and perforation.
Tips and Tricks for Treating Anterior Epistaxis With Cautery
Elevating the patient's chair to eye height is easier on the practitioner's back than bending down.
When using silver nitrate sticks, apply gentle rather than firm pressure to avoid cauterizing too deeply.
When using silver nitrate, start peripherally around the site of bleeding and work toward the center. Avoid cauterizing large areas of mucosa.
Reinspect the nasal cavity 10 to 15 minutes after completion of cauterization to ascertain that bleeding has not restarted.
Drugs Mentioned In This Article
|No brand name available
|AK-Tracin, Baciguent, BaciiM, Baci-Rx, Ocu-Tracin
|AK-T Caine, Pontocaine, Pontocaine in Dextrose, Pontocaine Niphanoid, Tetcaine, TetraVisc, TetraVisc Forte, Viractin
|7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme with Lidocaine, AsperFlex, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidocan III, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Dologesic, Ela-Max, GEN7T, Glydo, Gold Bond, LidaFlex, LidaMantle, Lido King Maximum Strength, Lidocan, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , LidoLite, Lidomar , Lidomark, LidoPure, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, Lidosol, Lidosol-50, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lubricaine For Her, Lydexa, Moxicaine, Numbonex, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Salonpas Lidocaine, Senatec, Solarcaine, SUN BURNT PLUS, Tranzarel, Xyliderm, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, Zingo, Zionodi, ZTlido
|12 Hour Nasal , Afrin, Afrin Extra Moisturizing, Afrin Nasal Sinus, Afrin No Drip Severe Congestion, Dristan, Duration, Genasal , Mucinex Children's Stuffy Nose, Mucinex Full Force, Mucinex Moisture Smart, Mucinex Sinus-Max, Mucinex Sinus-Max Sinus & Allergy, NASAL Decongestant, Nasal Relief , Neo-Synephrine 12-Hour, Neo-Synephrine Severe Sinus Congestion, Nostrilla Fast Relief, Reliable-1 12 hour Decongestant, Rhinase D, RHOFADE, Sinex 12-Hour, Sudafed OM Sinus Cold Moisturizing, Sudafed OM Sinus Congestion Moisturizing, Upneeq, Vicks Qlearquil Decongestant, Vicks Sinex, Vicks Sinex Severe, Visine L.R., Zicam Extreme Congestion Relief, Zicam Intense Sinus
|Anacin Adult Low Strength, Aspergum, Aspir-Low, Aspirtab , Aspir-Trin , Bayer Advanced Aspirin, Bayer Aspirin, Bayer Aspirin Extra Strength, Bayer Aspirin Plus, Bayer Aspirin Regimen, Bayer Children's Aspirin, Bayer Extra Strength, Bayer Extra Strength Plus, Bayer Genuine Aspirin, Bayer Low Dose Aspirin Regimen, Bayer Womens Aspirin , BeneHealth Aspirin, Bufferin, Bufferin Extra Strength, Bufferin Low Dose, DURLAZA, Easprin , Ecotrin, Ecotrin Low Strength, Genacote, Halfprin, MiniPrin, St. Joseph Adult Low Strength, St. Joseph Aspirin, VAZALORE, Zero Order Release Aspirin, ZORprin