Hematemesis and melena from upper gastrointestinal hemorrhage can often be overlooked. Elicit history of local trauma, including nose picking, possible foreign body (particularly batteries in children), and recurrent upper respiratory tract infections.
Treatments, including methods previously used to control episodes, can be instructive. Pinching over the nasal bones—rather than the soft cartilaginous part of the nose—unfortunately remains relatively common. Ask about any past medical history that can give clues to the cause of bleeding, such as hypertension, hepatic impairment, easy bruising, family history of coagulation disorders, and social history including alcohol intake, smoking, and recreational drug use—particularly cocaine use. A detailed medication history, as discussed earlier, is vital.
Initial management: Digital pressure
Epistaxis is potentially a life-threatening event. All patients who are actively bleeding require full assessment, resuscitation, and control of the bleeding.4 To protect the airway sit the patient upright and lean them forward to prevent aspiration of blood posteriorly into the pharynx. To control bleeding, get the patient to apply digital pressure at the cartilaginous part of the nose for a minimum of 10 minutes. This provides tamponade of the anterior septal vessels. Applying ice packs around the neck and having the patient suck on ice significantly reduces nasal mucosa blood flow and can slow down the bleeding.7
If there is significant bleeding
Monitor the patient’s vital signs, in particular, the pulse and respiratory rate. Assess the patient’s hemodynamic stability and look for signs of shock, such as sweating and pallor. Insert 2 large-bore (16 G) intravenous cannula and draw blood for type and crossmatch for potential transfusion if significant bleeding has occurred, in high risk patients (eg patients who are elderly or anticoagulated or have a suspected bleeding diathesis), or if further bleeding is likely to occur.2
Consider fluid resuscitation with intravenous saline initially and blood transfusions based on hemoglobin level, symptoms, and history of ischemic heart disease.3,6 Routine clotting studies need to be performed if there is a suspected bleeding diathesis or the patient is anticoagulated. Test for hepatic or renal dysfunction in patients with systemic conditions that could lead to coagulopathy. The clinical state of an elderly patient may deteriorate rapidly, so aggressive resuscitation is vital.4
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