Applied Evidence

Epistaxis: A guide to assessment and management

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Getting a better look requires the proper equipment

Universal precautions including facemask, eye protection, and gloves should be worn. Have equipment easily accessible, including sufficient lighting and suction. A headlight enables the use of both hands to assess and treat the patient. The nasal cavity often is obscured by clots, so ask the patient to blow and clear their nose. Although this may lead to a recurrence of bleeding, it could assist in identifying the bleeding point.2

Local anesthetic with a vasoconstrictor should be applied to the nasal mucosa over Little’s area either via a solution applied on cotton-tipped applicator or as a nasal spray. Once adequate local anesthesia is achieved, the nasal cavity can be examined and treatment instigated to stem the hemorrhage. Perform anterior rhinoscopy with a Thudicum’s speculum with one hand (FIGURE 2) while suctioning simultaneously with the other. Assess the nasal cavity systematically, paying particular attention to the septum and Little’s area for an anterior bleed. Look for scabbed and excoriated areas.

Thudicum’s speculum

Anterior bleeds can be managed safely in primary care, provided that appropriate equipment is available. Consider transfer to an emergency department or referral to an ENT specialist if bleeding continues or if a posterior bleed is suspected.2 Examination of the entire nasal cavity via nasendoscopy may be required to identify the source of bleeding—especially with posterior bleeds.

Nonsurgical management

Topical agents

Topical vasoconstrictor and local anaesthetic agents are widely available, and their limited adverse effect profiles make them a convenient first-line therapy.6,8 These agents reduce hemorrhage to allow for better visualization and analgesia for possible cautery or nasal packing.2 Common preparations include cophenylcaine (topical 5% lidocaine solution with 0.5% phenylephrine) and lidocaine injection (0.5%, 1%, or 2%) with epinephrine 1 in 200,000 and cocaine topical solutions (2% or 5%). Topical tranexamic acid has shown significant benefits in acute epistaxis in a systematic review.9


If direct pressure and medical therapy fail to stop the bleeding, cautery or nasal packing can be performed.2,8 Chemical cautery entails application of 75% silver nitrate sticks to the bleeding point with firm pressure for 5 to 10 seconds to produce a local chemical burn.4 Only one side of the septum should be cauterized, as there is a small risk of septal perforation resulting from decreased vascularization to the septal cartilage.2,4,8 This can be performed at 4 to 6 week intervals. Electric bipolar cautery with a metal loop is performed by otolaryngologists under local anesthesia.4 Compared with electric cautery, silver nitrate cautery is cheap, readily available, easy to perform, equal in effectiveness, and has fewer complications.10

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