Epistaxis medical therapy: Difference between revisions

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{{Epistaxis}}
{{Epistaxis}}
{{CMG}} ; '''Associate Editor(s)-in-Chief''':[[User:Amir Bagheri|Amir Behzad Bagheri, M.D.]]
{{CMG}} ; '''Associate Editor(s)-in-Chief''':[[User:Amir Bagheri|Amir Behzad Bagheri, M.D.]] {{Jose}}
 
<br />


==Overview==
==Overview==
Most of the time no action is needed to stop [[epistaxis]]. In active [[bleeding]] nasal compression is the first line to stop bleeding. If [[bleeding]] continues there are other options like [[cautery]] and some [[vasoconstrictive]] agents like [[oxymetazoline]] or [[phenylephrine]] to control [[bleeding]].
Most of the time no action is needed to stop [[epistaxis]]. In active [[bleeding]], nasal compression is the first line strategy to stop bleeding. If [[bleeding]] continues there are other options such as [[cautery]] and [[vasoconstrictive]] agents such as [[oxymetazoline]] or [[phenylephrine]] to control [[bleeding]].


==Medical Therapy==
==Medical Therapy==
If nasal bleeding is active and nasal compression couldn't stop [[bleeding]], there are the following medical options:<ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref> <ref name="KremplNoorily2016">{{cite journal|last1=Krempl|first1=Greg A.|last2=Noorily|first2=Allen D.|title=Use of Oxymetazoline in the Management of Epistaxis|journal=Annals of Otology, Rhinology & Laryngology|volume=104|issue=9|year=2016|pages=704–706|issn=0003-4894|doi=10.1177/000348949510400906}}</ref> <ref name="MontastrucMontastruc2014">{{cite journal|last1=Montastruc|first1=François|last2=Montastruc|first2=Guillaume|last3=Taudou|first3=Marie-Josée|last4=Olivier-Abbal|first4=Pascale|last5=Montastruc|first5=Jean-Louis|last6=Bondon-Guitton|first6=Emmanuelle|title=Acute Coronary Syndrome After Nasal Spray of Oxymetazoline|journal=Chest|volume=146|issue=6|year=2014|pages=e214–e215|issn=00123692|doi=10.1378/chest.14-1873}}</ref> <ref name="KrulewitzFix2019">{{cite journal|last1=Krulewitz|first1=Neil Alexander|last2=Fix|first2=Megan Leigh|title=Epistaxis|journal=Emergency Medicine Clinics of North America|volume=37|issue=1|year=2019|pages=29–39|issn=07338627|doi=10.1016/j.emc.2018.09.005}}</ref> <ref name="DouglasWormald2007">{{cite journal|last1=Douglas|first1=Richard|last2=Wormald|first2=Peter-John|title=Update on epistaxis|journal=Current Opinion in Otolaryngology & Head and Neck Surgery|volume=15|issue=3|year=2007|pages=180–183|issn=1068-9508|doi=10.1097/MOO.0b013e32814b06ed}}</ref>  
If nasal bleeding is active and nasal compression cannot stop the [[bleeding]], there are the following medical options:<ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref> <ref name="KremplNoorily2016">{{cite journal|last1=Krempl|first1=Greg A.|last2=Noorily|first2=Allen D.|title=Use of Oxymetazoline in the Management of Epistaxis|journal=Annals of Otology, Rhinology & Laryngology|volume=104|issue=9|year=2016|pages=704–706|issn=0003-4894|doi=10.1177/000348949510400906}}</ref> <ref name="MontastrucMontastruc2014">{{cite journal|last1=Montastruc|first1=François|last2=Montastruc|first2=Guillaume|last3=Taudou|first3=Marie-Josée|last4=Olivier-Abbal|first4=Pascale|last5=Montastruc|first5=Jean-Louis|last6=Bondon-Guitton|first6=Emmanuelle|title=Acute Coronary Syndrome After Nasal Spray of Oxymetazoline|journal=Chest|volume=146|issue=6|year=2014|pages=e214–e215|issn=00123692|doi=10.1378/chest.14-1873}}</ref> <ref name="KrulewitzFix2019">{{cite journal|last1=Krulewitz|first1=Neil Alexander|last2=Fix|first2=Megan Leigh|title=Epistaxis|journal=Emergency Medicine Clinics of North America|volume=37|issue=1|year=2019|pages=29–39|issn=07338627|doi=10.1016/j.emc.2018.09.005}}</ref> <ref name="DouglasWormald2007">{{cite journal|last1=Douglas|first1=Richard|last2=Wormald|first2=Peter-John|title=Update on epistaxis|journal=Current Opinion in Otolaryngology & Head and Neck Surgery|volume=15|issue=3|year=2007|pages=180–183|issn=1068-9508|doi=10.1097/MOO.0b013e32814b06ed}}</ref>  
 
*General management of patients is important. Stabilizing the patient and treating the specific cause is the basis of management.
*<br />General management of patients is important. Stabilizing the patient and treating the specific cause is the basis of management.
*At first [[airway]], [[breathing]] and [[circulation]] should be evaluated.
 
An algorithm for the management of epistaxis is depicted below:<ref name="pmid29345234">{{cite journal| author=Beck R, Sorge M, Schneider A, Dietz A| title=Current Approaches to Epistaxis Treatment in Primary and Secondary Care. | journal=Dtsch Arztebl Int | year= 2018 | volume= 115 | issue= 1-02 | pages= 12-22 | pmid=29345234 | doi=10.3238/arztebl.2018.0012 | pmc=5778404 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29345234  }} </ref>
*<br />At first [[airway]] , [[breathing]] and [[circulation]] should be evaluated.
{{familytree/start}}
{{familytree | | | | | | | | | | | | | Z01 | | | | |Z01='''[[Epistaxis]]'''<br>Treatment by a primary care physician or emergency physician}}
{{familytree | | | | | | | | | | | | | |!| | | | |}}
{{familytree | | | | | |,|-|-|-|-|-|-| A01 |-|-|-|-|.| |A01=❑ '''Compression of the [[nostrils]]<br>❑ Ice  application to the neck area<br>❑ Upright sitting position<br>❑ Blood to be spat out<br>❑ Take [[blood pressure]], lower if appropriate'''}}
{{familytree | | | | | K01 | | | | | | |!| | | | | K02 | |K01=Patient '''hemodinamically stable''', [[bleeding]] '''stops'''|K02= Patient '''hemodinamically unstable'''}}
{{familytree | | | | | |!| | | | | | | B01 | | | | |!| | |B01=Patient '''hemodinamically stable''', [[bleeding]] '''persists'''}}
{{familytree | |,|-|-| L01 |-|.| | | | |!| | | | | L02 | |L01=❑ 30min observation,<br>❑ [[Antiseptic]] nasal cream|L02=❑ '''Emergency''' transfer to '''ENT''' department<br>❑ '''[[Volume]] replacement'''}}
{{familytree | C02 | | | | | | C03 |~| C01 | | | | |!| | |C02='''[[Bleeding]] stops:'''<br>❑ Discharge patient home<br>❑ Prevent recurrence;<br>❑ Nasal mucosal care <br>❑ No nose-blowing for 7-10 days|C01= '''Emergency referral to otorhinolaryngologist'''|C03= '''[[Bleeding]] resumes'''}}
{{familytree | | | | | | | | | | | | | |!| | | | | |!|}}
{{familytree | | | | | | | | | | | | | Y01 | | | | |!| |Y01='''Anterior [[rhinoscopy]]'''<br>'''[[Endoscopy]]''' if required}}
{{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| |!|}}
{{familytree | | | | | | | | | D01 | | | | | | D02 |!|D01= Source of [[bleeding]] visible, '''anterior'''|D02= Source of [[bleeding]] not visible and/or '''posterior'''}}
{{familytree | | | | | | | | | |!| | | | | | | |!| |!|}}
{{familytree | | | | E00 |-|-| E01 |~| E03 | | E02 |!| | | | | | | | | |E00= '''[[Bleeding]] stops:'''<br>❑ Discharge patient home<br>❑ Prevent recurrence;<br>❑ Nasal mucosal care <br>❑ No nose-blowing for 7-10 days|E01= '''[[Eletrocoagulation]]''' or '''[[silver nitrate]] [[cautery]]''';<br>'''[[Hemostatic gauze]]''' if required|E03= '''[[Bleeding]] persists:'''<br>Nasal packing|E02= '''Nasal packing'''}}
{{familytree | | | | | | | | | | | | | |!|,|-|-|-|-|'| | | | | |}}
{{familytree | | | | | | | | | | | | | K01 | | | | | |K01=Treatment of [[epistaxis]] in the '''ENT department'''}}
{{familytree | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | | | | | | J01 | | J02 | | | J03 | | | | | | | | | |J01= '''[[Bleeding]] stops'''|J02= '''[[Bleeding]] persists, patient fit for [[surgery]]'''|J03='''[[Bleeding]] persists, patient not fit for [[surgery]]'''}}
{{familytree | | | | | | | | | |!| | | |!| | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | M01 | | M02 | | | M03 | | | | | | | | |M01= '''Remove packing after 48h''', '''[[antibiotics]]''' if needed|M02='''Surgical treatment''', usually '''[[endoscopic sphenopalatine ligation]]'''|M03= '''[[Embolization]]'''}}
{{familytree | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | N01 | | N02 | | | | | | | | | | | | |N01= If [[bleeding]] persists, '''embolization'''|N02=If [[bleeding]] persists:<br>Patient fit for [[surgery]] - '''[[surgery]]'''<br> Patient not fit for [[surgery]] - '''[[embolization]]'''|}}
{{familytree/end}}


'''Medical Therapy:'''
'''Medical Therapy:'''
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*'''[[Antifibrinolytic]]''':
*'''[[Antifibrinolytic]]''':
**Preferred regimen (1): [[Tranexamic acid]] ([[Tranexamic acid|TXA]]) ([[Topical]] ).<br />
**Preferred regimen (1): [[Tranexamic acid]] ([[Tranexamic acid|TXA]]) ([[Topical]] ). In [[coagulopathy]] and [[Hereditary hemorrhagic telangiectasia|HHT]] patients is preferred.<br />


*'''[[Chemical]] [[cauterization]]''' ( At first [[anesthesia]] [[bleeding]] site and limit nasal [[cautery]] to site''':'''  
*'''[[Chemical]] [[cauterization]]''' (At first [[anesthesia]] [[bleeding]] site and limit nasal [[cautery]] to site''':'''  
**Preferred regimen (1): [[Silver nitrate]] 25%-75%
**Preferred regimen (1): [[Silver nitrate]] 25%-75%
**Alternative regimen (1): [[Chromic acid]]
**Alternative regimen (1): [[Chromic acid]]
Line 31: Line 51:


*Some [[Medicine|medicines]] are used to prevent [[epistaxis]]:
*Some [[Medicine|medicines]] are used to prevent [[epistaxis]]:
**'''[[Emollient]] [[Cream (pharmaceutical)|creams]] :''' Continues using of topical [[emollient]] [[Cream (pharmaceutical)|creams]] is useful to prevent [[epistaxis]].
**'''[[Emollient]] [[Cream (pharmaceutical)|creams]]:''' Continues using of topical [[emollient]] [[Cream (pharmaceutical)|creams]] is useful to prevent [[epistaxis]].
**'''[[Ointment|Ointments]] :''' Continues using of topical [[Ointment|ointments]] is useful to prevent [[epistaxis]]
**'''[[Ointment|Ointments]]:''' Continues using of topical [[Ointment|ointments]] is useful to prevent [[epistaxis]]


==References==
==References==
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[[Category:Otolaryngology]]
[[Category:Otolaryngology]]
[[Category:Rhinology]]
[[Category:Rhinology]]
[[Category:First aid]]
[[Category:First aid]]
[[Category:Injuries]]
[[Category:Injuries]]
[[Category:Needs overview]]

Latest revision as of 14:37, 14 January 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief:Amir Behzad Bagheri, M.D. José Eduardo Riceto Loyola Junior, M.D.[2]

Overview

Most of the time no action is needed to stop epistaxis. In active bleeding, nasal compression is the first line strategy to stop bleeding. If bleeding continues there are other options such as cautery and vasoconstrictive agents such as oxymetazoline or phenylephrine to control bleeding.

Medical Therapy

If nasal bleeding is active and nasal compression cannot stop the bleeding, there are the following medical options:[1] [2] [3] [4] [5]

  • General management of patients is important. Stabilizing the patient and treating the specific cause is the basis of management.
  • At first airway, breathing and circulation should be evaluated.

An algorithm for the management of epistaxis is depicted below:[6]

 
 
 
 
 
 
 
 
 
 
 
 
Epistaxis
Treatment by a primary care physician or emergency physician
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Compression of the nostrils
❑ Ice application to the neck area
❑ Upright sitting position
❑ Blood to be spat out
❑ Take blood pressure, lower if appropriate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient hemodinamically stable, bleeding stops
 
 
 
 
 
 
 
 
 
 
 
 
Patient hemodinamically unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient hemodinamically stable, bleeding persists
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 30min observation,
Antiseptic nasal cream
 
 
 
 
 
 
 
 
 
 
 
 
 
Emergency transfer to ENT department
Volume replacement
 
 
 
 
 
 
 
Bleeding stops:
❑ Discharge patient home
❑ Prevent recurrence;
❑ Nasal mucosal care
❑ No nose-blowing for 7-10 days
 
 
 
 
 
Bleeding resumes
 
Emergency referral to otorhinolaryngologist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anterior rhinoscopy
Endoscopy if required
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source of bleeding visible, anterior
 
 
 
 
 
Source of bleeding not visible and/or posterior
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleeding stops:
❑ Discharge patient home
❑ Prevent recurrence;
❑ Nasal mucosal care
❑ No nose-blowing for 7-10 days
 
 
Eletrocoagulation or silver nitrate cautery;
Hemostatic gauze if required
 
Bleeding persists:
Nasal packing
 
Nasal packing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment of epistaxis in the ENT department
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleeding stops
 
Bleeding persists, patient fit for surgery
 
 
Bleeding persists, patient not fit for surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Remove packing after 48h, antibiotics if needed
 
Surgical treatment, usually endoscopic sphenopalatine ligation
 
 
Embolization
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If bleeding persists, embolization
 
If bleeding persists:
Patient fit for surgery - surgery
Patient not fit for surgery - embolization
 
 
 
 
 
 
 
 
 
 
 
 

Medical Therapy:

References

  1. Tunkel, David E.; Anne, Samantha; Payne, Spencer C.; Ishman, Stacey L.; Rosenfeld, Richard M.; Abramson, Peter J.; Alikhaani, Jacqueline D.; Benoit, Margo McKenna; Bercovitz, Rachel S.; Brown, Michael D.; Chernobilsky, Boris; Feldstein, David A.; Hackell, Jesse M.; Holbrook, Eric H.; Holdsworth, Sarah M.; Lin, Kenneth W.; Lind, Meredith Merz; Poetker, David M.; Riley, Charles A.; Schneider, John S.; Seidman, Michael D.; Vadlamudi, Venu; Valdez, Tulio A.; Nnacheta, Lorraine C.; Monjur, Taskin M. (2020). "Clinical Practice Guideline: Nosebleed (Epistaxis)". Otolaryngology–Head and Neck Surgery. 162 (1_suppl): S1–S38. doi:10.1177/0194599819890327. ISSN 0194-5998.
  2. Krempl, Greg A.; Noorily, Allen D. (2016). "Use of Oxymetazoline in the Management of Epistaxis". Annals of Otology, Rhinology & Laryngology. 104 (9): 704–706. doi:10.1177/000348949510400906. ISSN 0003-4894.
  3. Montastruc, François; Montastruc, Guillaume; Taudou, Marie-Josée; Olivier-Abbal, Pascale; Montastruc, Jean-Louis; Bondon-Guitton, Emmanuelle (2014). "Acute Coronary Syndrome After Nasal Spray of Oxymetazoline". Chest. 146 (6): e214–e215. doi:10.1378/chest.14-1873. ISSN 0012-3692.
  4. Krulewitz, Neil Alexander; Fix, Megan Leigh (2019). "Epistaxis". Emergency Medicine Clinics of North America. 37 (1): 29–39. doi:10.1016/j.emc.2018.09.005. ISSN 0733-8627.
  5. Douglas, Richard; Wormald, Peter-John (2007). "Update on epistaxis". Current Opinion in Otolaryngology & Head and Neck Surgery. 15 (3): 180–183. doi:10.1097/MOO.0b013e32814b06ed. ISSN 1068-9508.
  6. Beck R, Sorge M, Schneider A, Dietz A (2018). "Current Approaches to Epistaxis Treatment in Primary and Secondary Care". Dtsch Arztebl Int. 115 (1–02): 12–22. doi:10.3238/arztebl.2018.0012. PMC 5778404. PMID 29345234.

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