2.5 : Epistaxis

Epistaxis, or nosebleeds, occurs when small, swollen blood vessels in the nasal mucous membrane rupture. Typically, the anterior septum is the primary site of occurrence.

Etiology

Possible causes of this condition include high blood pressure, trauma, low humidity, upper respiratory tract infections, allergies, foreign bodies, nasal inhalation of corticosteroids or illicit drugs, excessive use of decongestant nasal sprays, facial or nasal surgery, anatomic malformation, tumors, or systemic infections such as scarlet fever.

Management

Management of epistaxis depends on its cause and the location of the bleeding site. A nasal speculum, penlight, or headlight may be used to identify the site of bleeding in the nasal cavity.

For initial treatment, the patient should be placed in a sitting position, leaning slightly forward, with the head tilted forward. This posture helps prevent swallowing and aspiration of blood. Next, apply direct pressure by pinching the nose's soft outer portion against the midline septum continuously for 5 or 10 minutes. Finally, administer nasal decongestants such as phenylephrine, which can act as vasoconstrictors with one or two sprays.

If these measures are unsuccessful in stopping the bleeding, further intervention is required:

• Examine the nose using good illumination and suction to determine the bleeding site.

• Apply a supplemental patch of absorbable materials, such as oxidized cellulose, gelatin foam, or a gelatin-thrombin combination. These patches stop bleeding, promote clotting, and shield the nasal mucosa from drying out or additional injury.

For severe bleeding, visible bleeding sites may be chemically cauterized with silver nitrate or thermal cauterization.

To treat an anterior nasal septum bleed, a pledget or nasal tampon infused with an anesthetic solution (lidocaine) and vasoconstrictive agents (epinephrine) can be inserted into the nasal cavity.

Nasal packing is the preferred treatment option to treat posterior nasal septum bleeds. It can involve using compressed nasal sponges or epistaxis balloons.

Nasal sponges are inserted into the nares and gently advanced along the floor of the nasal cavity. As it absorbs moisture, the sponge expands, filling the nasal cavity and providing hemostasis.

An epistaxis balloon can be inserted into the nares and inflated with air to achieve the same pressure effect.

Keeping the packing in position for 3 to 4 days is recommended to manage bleeding. Antibiotics may also be prescribed as a precautionary measure due to the potential risk of developing iatrogenic rhinosinusitis and sepsis. All patients with posterior packing should be placed in a monitored unit for close observation due to the increased risk of complications.

Nursing Interventions

Vigilantly monitor the patient's level of consciousness, heart rate, rhythm, respiratory rate, and oxygen saturation using pulse oximetry. Observe for any signs of breathing or swallowing difficulties.

Patient Education

Once the bleeding is under control, advise the patient to refrain from vigorous exercise for several days and to avoid consuming hot or spicy foods and using tobacco, as these may cause vasodilation and increase the risk of rebleeding. Educate the patient on preventive measures for epistaxis, including avoiding forceful nose blowing, straining, high altitudes, nasal trauma, and nose picking. Ensuring adequate nasal humidification can help prevent dryness. It is also recommended that the nose be moistened with petroleum jelly (Vaseline).