Treating local and systemic nosebleeds

THE BASICS 

A bleeding nose cannot always be dealt with in the surgery, explains Dr Lizzie Croton.

Epistaxis is a common problem in general practice. As a GP you are either faced with a patient complaining of recurrent nosebleeds, or the more acute situation where the patient is actively hosing blood in front of you.

Always treat bleeding noses with respect because the blood loss can cause severe systemic physiological changes and in some cases it can be fatal.

The most important area to be concerned with in epistaxis is Little's area, situated at the anterior inferior nasal septum where the sphenopalatine, anterior ethmoid and superior labial arteries anastomose to form a rich superficial plexus. This is the most common site for all nosebleeds.

Trauma is the most common cause. Toddlers and young children who pick their noses and insert foreign bodies are the usual culprits. Nasal fractures from falls and assaults will cause bleeding. Fractures of the skull and sinuses can also present with epistaxis.

Local causes of bleeding

From the age of 40, the site for epistaxis moves posteriorly in the nasal cavity to cause more posterior bleeding. This can

be harder to treat as the bleeding point is less visible. Atherosclerotic changes in the arteries are thought to make the vessels more likely to rupture.

Bleeding can occur after nasal surgery, in particular post septoplasty. I would always refer these patients back to the hospital as some may have packs or splints in situ.

Systemic causes of bleeding

The patient's medication is the most common cause for systemic bleeding. They may well be taking warfarin, aspirin or other NSAIDS.

Some NSAIDS can be bought without prescription and it is important to ask specifically about use of these drugs.

Haematological disorders such as hereditary haemorrhagic telangiectasia and the bleeding diatheses can also cause epistaxis. Always bear in mind that some neoplasms can present with epistaxis.

Occupational causes include smoking and certain occupations, for example working with hard woods. Unilateral polyps should be regarded as potentially malignant and should be referred.

Management

To manage an acute bleed you will need an extra pair of hands and a good light. This light can be held by the assistant or even better obtain a head-mounted camping light from an outdoor store. These are inexpensive and useful for routine nasal examination.

If you can see a bleeding point around Little's area, direct digital pressure on the lower nose for at least five minutes. It is possible to cauterise a bleeding point directly with a silver nitrate stick if you can see the vessel.

Cauterising bleeding

Use a Thudichum speculum to lift and separate the external nares to view Little's area. Cautery is painful and the nasal mucosa can be anaesthetised with lignocaine spray or a cotton wool ball soaked in lignocaine, placed just inside the nares.

If you are unsuccessful or cannot see a bleeding point, consider packing one or both nostrils if you have the experience. Ribbon gauze with vaseline or bismuth iodoform paraffin paste (BIPP) can be used. It is kinder to the patient if you use local anaesthetic first. Ready-made nasal tampons can be lubricated and inserted into the nose. These can either be foam or packs designed to be inflated with water.

Patients presenting with acute epistaxis tend to be elderly with bleeding from atherosclerotic arterioles.

Remember to sit up these patients and check their vital signs. Urgent transfer to hospital will be required if the patient is shocked. If bleeding doesn't stop the patient should be sent to the hospital urgently in an ambulance.

Non-acute bleeding

Little's area should be inspected in any patient with a history of epistaxis. It may be possible to cauterise the offending vessel with silver nitrate.

In children a cream containing chlorhexidine and neomycin may be used twice daily for a week. It is important to ensure the child 'sniffs' a blob of cream up the nostril rather than trying to wipe it on to Little's area.

Dr Lizzie Croton is a GP registrar in Northumberland

MANAGING NOSEBLEEDS

- Cauterise a bleeding point directly with a silver nitrate stick if vessel is visible.

- Local anaesthesia (lignocaine) should be used prior to cauterisation.

- Pack the nostrils with ribbon gauze, Vaseline or bismuth iodoform paraffin paste if you cannot see a bleeding point.

- If the bleeding doesn't stop, patients require urgent hospital transfer.

- Children can be given chlorhexidine and neomycin cream twice daily for a week.

REFERENCES

- McIntosh L, 2004. Anterior epistaxis - does cooling reduce bleeding? Best Evidence Topics. http://www.bestbets.org/cgi-bin/bets.pl?record=00568

- Ghosh A, 2001. Cautery or cream for epistaxis in children? Best Evidence Topics. www.bestbets.org/cgibin/bets.pl?record=00215.

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