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How To Treat Epistaxis With Cautery

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Epistaxis (nasal hemorrhage) can often be stopped with cautery (sealing off a blood vessel using current or chemicals).

Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis may be treated by pinching the nares closed for 10 full minutes. If pinching is unsuccessful and the bleeding site is visible and localized, the next step is to use cautery, followed by nasal tamponade if cautery is unsuccessful or not indicated. Posterior epistaxis is managed quite differently so identifying the site of bleeding is critical.

(See also Epistaxis.)

Indications

  • Anterior nasal bleeding from a clearly visible site

Anterior bleeding sites are usually apparent on direct examination. If no site is apparent and there have been only 1 or 2 minor nosebleeds, no further examination is needed. If bleeding is continuing or recurrent and no site is seen, it may be necessary to use an anterior tamponade method.

Contraindications

Absolute contraindications

  • Inability to see the source of bleeding

Procedures described here are intended for epistaxis that is spontaneous or resulting from minor trauma. Epistaxis in patients with significant facial trauma should be managed by a specialist.

Relative contraindications

  • Patients with a pacemaker and/or defibrillator may require cardiology consultation before doing monopolar electrocauterization.

  • Patients with a cochlear implant may not be able to undergo monopolar electrocauterization.

Complications

  • Injury or perforation of the nasal septum, particularly from multiple, overly aggressive or bilateral attempts at cauterization

  • Intranasal adhesions

Equipment

  • Gloves, mask, and gown

  • Gown or drapes for patient

  • Suction source and Frazier-tip and/or other suction-tip suction catheters

  • Sterile gauze sponges

  • Emesis basin

  • Chair with headrest or an ear, nose, and throat (ENT) specialist's chair

  • Light source and head mirror or headlamp with adjustable narrow beam

  • Nasal speculum

  • Tongue depressors

  • Frazier-tip suction catheter

  • Silver nitrate sticks or electrocautery

  • Antibiotic ointment (eg, bacitracin)

  • Topical anesthetic/vasoconstrictor mixture (eg, 4% cocaine, 1% tetracaine, or 4% lidocaine plus 0.5% oxymetazoline) or topical vasoconstrictor alone (eg, 0.5% oxymetazoline spray)

  • Cotton swabs or pledgets

Additional Considerations

  • Ask about use of anticoagulant or antiplatelet drugs.

  • Check complete blood count (CBC), prothrombin time (PT), and partial thromboplastin time (PTT) if there are symptoms or signs of a bleeding disorder or the patient has severe or recurrent epistaxis.

Relevant Anatomy

  • Kiesselbach's plexus is a vascular watershed area on the anterior nasal septum that is the most common site of anterior epistaxis.

Positioning

  • The patient should sit upright in the sniffing position with the head extended, preferably in an ENT specialist's chair. The patient's occiput should be supported to prevent sudden backward movement. The patient's nose should ideally be level with the physician's eyes.

  • The patient should hold the emesis basin to collect any continued bleeding or emesis (eg, of swallowed blood).

Step-by-Step Description of Procedure

  • Have the patient gently blow the nose to remove clots, or suction the nasal passageway carefully.

  • Insert a nasal speculum with your index finger resting against the patient's nose and the handle parallel to the floor (so the blades open vertically).

  • Slowly open the speculum and examine the nose using a bright headlamp or head mirror, leaving one hand free to manipulate suction or an instrument.

  • Use a Frazier-tip suction catheter to remove any blood and clots obscuring the view.

  • Look for blood flowing from the anterior septum in the area of Kiesselbach's plexus, and look for blood flowing from the back of the nose.

  • Apply a topical vasoconstrictor/anesthetic mixture: Place about 3 mL of 4% cocaine solution or 4% lidocaine with oxymetazoline in a small medicine cup and soak 2 or 3 cotton pledgets with the solution and insert them into the nose, stacked vertically (or spray in a topical vasoconstrictor such as oxymetazoline and place pledgets containing only topical anesthetic).

  • Leave the topical drugs in place for 10 to 15 minutes to stop or reduce the bleeding, provide anesthesia, and reduce mucosal swelling.

  • Use silver nitrate sticks to cauterize the site only if vasoconstriction has stopped the bleeding and the bleeding site is clearly visible. Place the tip of the silver nitrate stick against the site and roll the tip over the bleeding site for 4 to 5 seconds until an eschar forms. This will turn the mucosa a grayish color.

  • Wipe or suction away any excess silver nitrate to avoid any further cautery at this site or other sites in the nose.

  • Patients often sneeze after silver nitrate cautery, which may restart bleeding (and splatter the operator with blood), necessitating repeat cautery.

  • If cautery has not stopped the bleeding after 2 attempts, another technique, such as a nasal tamponade, should be used.

  • After hemostasis is successful, apply antibiotic ointment (such as bacitracin) to the cauterized area.

Aftercare

  • Advise the patient not to use aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 days after treatment of epistaxis.

  • The cauterized area should be coated with petroleum jelly 2 to 3 times a day for 3 to 5 days.

  • Advise the patient that if bleeding recurs, the nostrils should be pinched closed for 20 minutes without interruption. Applying oxymetazoline nasal spray before pinching the nostrils may help control bleeding. If this does not stop the bleeding or if the bleeding is profuse, the patient should return to the emergency department.

Warnings and Common Errors

  • Do not open the nasal speculum laterally or use the nasal speculum in an unsupported manner. (Brace a finger of the hand holding the speculum on the patient's cheek or nose.)

  • Avoid burning the mucous membrane too deeply. Cautery with silver nitrate is less likely to burn too deeply and is preferred to electrocautery.

  • Do not cauterize the nasal septum bilaterally because doing so increases the risk of septal injury and perforation.

Tips and Tricks

  • Elevating the patient's chair to eye height is easier on the practitioner's back than bending down.

  • When using silver nitrate sticks, apply gentle rather than firm pressure to avoid cauterizing too deeply.

  • When using silver nitrate, start peripherally around the site of bleeding and work toward the center. Avoid cauterizing large areas of mucosa.

  • Reinspect the nasal cavity 10 to 15 minutes after completion of cauterization to ascertain that bleeding has not restarted.

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