Epistaxis

A bleeding nose can be a very unnerving emergency; if you don't treat a patient correctly, it can be fatal. The measures described here will control the severest bleeding, but it commonly recurs.

Nose bleeds are rare in infancy, common in childhood, uncommon in young adults, and more common again in the elderly. Most bleeding is easily controlled, and has no obvious cause. Blood usually comes from the anterior septal vessels in the front of the nasal septum (Little's area, F, in Fig. 25-5). You can see these with a nasal speculum and a good light (try the sun) behind you; you will see them better with a head mirror. When bleeding comes from anywhere else, it usually comes from far back in the patient's nose. This is difficult to get at, and he is usually both elderly and hypertensive.

Try the simpler methods first. If you teach them to your nurses and auxiliaries, they will be able to treat most patients. You will need suction, and if possible a headlight and BIPP (4.11).

Fig. 25-5 EPISTAXIS. A, inserting an anterior nasal pack. B, to E, inserting a posterior nasal pack. B, passing a catheter. C, a gauze roll ready to be pulled into place. D, pushing the gauze roll into place. E, the gauze roll tied in place. F, a patient's anterior septal vessels (Little's area) have about a 50% chance of being the source of the bleeding. After Lor[ac]e JM, ''An Atlas of Head and Neck Surgery', Plate 51 WB Saunders, with kind permission.

NOSE BLEEDING EXAMINATION. Sit the patient upright looking straight ahead. Ask an assistant to stand behind him, and hold his head. If he is bleeding from the anterior half of his nasal cavity, most of the blood will come from his nostrils. If he is bleeding from the posterior half, much of it will be trickling down his pharynx.

A child is almost certainly bleeding from his anterior septal vessels; so are most adults. In the remaining cases, the bleeding is posterior, and is occasionally caused by a systemic disease.

DIFFERENTIAL DIAGNOSIS. Did the blood come first from his nostrils, or his nasopharynx? This will be some help in deciding where he is bleeding. Apart from obvious hypertension, there is usually no time to speculate on the cause. Other causes include trauma, a foreign body, tumours, onyalai, leukaemia, scurvy, purpura, and the prodromal stages of diphtheria, measles, varicella, and scarlet fever.

IMMEDIATE TREATMENT. Sit him forwards a little, drape him in a mackintosh, and hold his nose over a receiver. Tell him not to swallow the blood, but to spit it out. Avoid a stomach full of blood! If he cannot sit up lay him on his side.

Squeeze his nose, so that you press its soft mobile parts against his septum, while he breathes with his mouth wide open. Do this yourself, or delegate a nurse to do it. If bleeding is more than minimal, keep pressing for 5 minutes by the clock. If it is minimal, ask him to do it himself. If necessary, sedate him. If squeezing fails, try it again. If you wait long enough the bleeding will usually stop, and you will have done nothing to damage his mucosa.

If you decide that bleeding is not going to stop, put up a drip, take blood for cross-matching, and give him pethidine 50 or 100 mg intramuscularly, or slowly intravenously. He will now tolerate your manipulations more easily. Proceed with anterior packing.

ANTERIOR BLEEDING [s7]FROM THE NOSE ANAESTHESIA. All packing, intranasal manipulation or cauterization needs local anaesthesia, either by spray (A 5.8), or on a gauze or wool swab wet with 4% lignocaine.

ANTERIOR PACKING aims to provide a focus for the development of a firm clot close to the bleeding point. You will need a head mirror, with a good light shining on to it from behind his shoulder, a nasal speculum, and dressing forceps, preferably Tilley's. If you don't have a head mirror, a good light behind you will do. For each side of the nose you will need about a metre of 13 mm gauze packing, or a 13 mm roller bandage. To make this easier to remove later, smear it with vaseline, or ''BIPP' (4.11). If you lack BIPP, soak it in 1/100,000 adrenalin solution.

Pack the nostril which is bleeding most. Sit him upright, and ask an assistant to stand behind him and hold his head. Warn him that he will find the procedure very uncomfortable. Clear his nasal cavities by asking him to blow his nose, or clear his bleeding nasal cavity with a sucker and cannula. Your previously applied lignocaine pack should have produced some anaesthesia.

Focus your light on the speculum, and put it into his bleeding nostril. Grasp the end of the gauze with forceps and place it as high and as far back as you can. Try to pack his nasal cavity in an orderly way in horizontal layers, starting on its floor and working towards its roof. This is difficult, and you will probably find yourself putting gauze wherever it will go, until his nose is full. Leave both ends of the gauze protruding from his nostrils. If necessary, pack both sides of his nose, and secure all the four ends of the gauze with a safety pin. Strap a pad of folded gauze across the front of his nose, and wait a few minutes.

If an anterior pack controls bleeding, leave it in place for 48 hours. Then gently remove it, preferably early in the day, so that you can more easily repack his nose if necessary. Observe him carefully for 24 hours before you discharge him.

If an anterior pack does not control bleeding, remove it, insert a posterior one, and then repack his anterior nasal cavity as above.

CAUTERIZATION (optional). Soak a small piece of ribbon gauze in 4% lignocaine and adrenalin solution, squeeze out the excess, and apply this to the bleeding area for 10 minutes, or use a local anaesthetic spray. Use a nasal speculum, or a wide- bore aural speculum, and a good light, to find the bleeding vessels in Little's area. Touch them along their course with an applicator that has had a bead of silver nitrate fused to its tip. His mucosa will turn white.

If you fail to control bleeding, reinsert the lignocaine and adrenalin pack. If this too fails, hold a silver nitrate stick over the bleeding area for a few moments, and then roll it away to one side before you remove it (if you pull it off, bleeding may restart).

If you fail again, try a galvanocautery with a hot wire loop. If necessary, use any thin wire heated in a spirit lamp. Gently touch the bleeding area. You can also use diathermy, preferably under general anaesthesia. Leave the scab, and dress it with vaseline.

CAUTION ! (1) Don't cauterize both sides of his nasal septum at one time with silver nitrate or heat, because it may perforate.

POSTERIOR BLEEDING [s7]FROM THE NOSE POSTERIOR PACKING may be necessary if: (1) An anterior pack fails to control anterior bleeding. (2) There is severe posterior bleeding.

Take him to the theatre. Spray his pharynx and palate with 4% lignocaine.

Use a Foley catheter (often very effective). Start with this. Pass a Foley, with a reasonably sized balloon, gently through his anaesthetized nostril, until you see its tip just behind his soft palate. Inflate the balloon with air, and gently withdraw the catheter, so that the balloon impacts in his posterior nasal opening. Tape it to his cheek, then pack his nose from in front as described above.

CAUTION ! (1) Don't inflate the balloon in his nasal cavity, because this can quickly cause pressure necrosis of his mucosa, which may make bleeding worse. (2) The tube of the catheter can ulcerate the rim of his nasal entrance, so spread out the pressure by putting a little gauze pad under it.

Use a pack of folded or rolled gauze sponges of sufficient bulk to plug his posterior nares. If possible give him a general anaesthetic, and intubate him. You will need two packs, of at least 5 cm square for an adult. Tie 50 cm of soft string, or umbilical tape, to a small (18 Ch) rubber catheter, as in B, Fig. 25-5. Put this into one nostril, and pull it out of his mouth, leaving the string in place. Do the same thing on the other side.

Tie the oral ends of the strings to the pack, and tie a third piece of string to it. Pull the pack up into the back of his nose, and press it into place with your finger in his throat. Make sure that it has gone behind his soft palate, and that this has not folded upwards.

Then pack his anterior nasal cavity, as above.

Tie the nasal ends of the string over some gauze. Let the third string protrude from the corner of his mouth, and tape it to his cheek. Or keep it in place with a plastic umbilical cord clamp.

CAUTION ! (1) Insert packs with great gentleness: you can easily cause more bleeding as you insert them. (2) Withdraw the packs, or the Foley catheter, slowly after 48 hours. Don't leave any pack or catheter, either anterior or posterior, in his nose for longer than this, or you will increase the risk of suppuration, especially in his sinuses. The only possible exception is a pack impregnated with ''BIPP' (4.11), which you can leave for a week. If you are using a Foley, deflate it a little first to see if bleeding is controlled. (3) Remove a pack slowly, bit by bit.

When you remove a posterior pack, do so in the theatre, with a light and the necessary equipment ready, so that you can if necessary repack without delay.

Because epistaxis may recur when you allow him home, make sure he knows how to hold his nose, to breathe through his mouth, and to sit forwards in the correct position.

GENERAL MEASURES [s7]FOR EPISTAXIS Try to estimate how much blood he has lost. If he has been bleeding severely, watch for signs of shock. Keep him propped up in bed. Give him aspirin or paracetamol, if necessary. Pethidine or morphine can be helpful. Monitor his blood pressure, his respiration, and his haemoglobin. Most severe epistaxes are precipitated by infection, so give him a broad-spectrum antibiotic (ampicillin or chloramphenicol and metronidazole, 2.9) for at least 5 days. If you have to transfuse him, use fresh blood.

DIFFICULTIES [s7]WITH EPISTAXIS If anterior and/or posterior PACKING FAILS, make sure that the packs have not become loose. If so, replace them. Use not less than a metre of ribbon in each nostril. It is not possible to bleed through proper packing.

If he has been properly packed and CONTINUES TO BLEED whenever the packs are removed, anaesthetize and intubate him (you should be removing them in the theatre anyway). Failure of packs to control bleeding on one occasion is common, but they usually work eventually. The ultimate measure is to tie the arteries supplying his nose: (1) Start with his anterior ethmoidal, which is the easiest. (2) Alternatively, tie his external carotid (3.3). There is such an extensive collateral circulation that this often fails to help. (3) His internal maxillary artery can also be clipped, behind the posterior wall of his antrum, but this is an expert's task.

To tie his anterior ethmoidal artery, make a small incision 1 cm medial to his inner canthus. Cut down to bone, raise his periosteum, particularly posteriorly, so as to make a passage along the medial wall of his orbit. As you raise his periosteum, you will find it tethered at the point where his anterior ethmoidal artery crosses from his orbit to enter bone. Carefully dissect it. Diathermy it, clip it, or tie it with a small suture.

If he BLEEDS PERSISTENTLY, check for signs of a bleeding disorder. Look for petechiae, ecchymoses, and a large spleen. If possible, measure his clotting (16.13) and bleeding times, his prothrombin index, and his blood urea. If you find any abnormality, investigate him further. He may have leukaemia or thrombocytopenia, etc. Don't pack his nose. Instead, control the ooze by soaking oxidized cellulose sponges in topical thrombin solution (if you have it), and place these in his nose. If this fails or you cannot do it, you will have to pack his nose. He may die.

If HE IS ELDERLY, suspect that his bleeding nose may be serious. Enquire carefully for a history of illness, trauma, medication, or a bleeding disorder. If he is hypertensive, bleeding may be difficult to stop. He too may die.

MR PRINTER Please take in ''augmentation rhinoplasty?' somewhere here and delete this line; there is no caption and it is not numbered.