EPISTAXIS- Menacing but Manageable

EPISTAXIS is defined as bleeding from inside the nose. It is one of the most commonemergencies in the casualty department of health care establishments. It is believed thatapproximately 60% of the population will be affected by epistaxis at some point in theirlifetime.

Although Epistaxis presents a scary situation to the patient and the attendants, in most cases, it is mild, the treatment is simple, and hospitalisation is not required. It can affect any age groupand both genders. However, Epistaxis is frequentlyassociated with male gender, autumn andwinter months, children, young adults and the elderly.

One of the primary functions of the nose is to warm and humidify air, and therefore it has aprofuse blood supply within the nasal mucosa that runs superficially and hence easily proneto bleed. Local causes of nosebleed include inflammation and infection (rhinitis), trauma(Road Traffic Accidents), abnormal anatomy (deviated nasal septum), chemicals (fumes), neoplasm (cancer of the nose) and foreign body (small toy parts entering the nose). Systemic causesinclude coagulopathies ie Blood’s ability to clot is impaired (eg, haemophilia), thrombocytopenia (i.e., low level of platelets (eg, leukaemia), platelet dysfunction (VonWillebrand’s disease) and organ failure (cirrhosis). Drugs that cause epistaxis includeAnticoagulants like heparin and Antiplatelets like aspirin. Hypertension is a common findingin the elderly presenting with epistaxis. Smoking and alcohol use are common habits among adult sufferers. Nose blowing habit, excessive coughing in chronic obstructive pulmonary disease(bronchitis), straining in constipation, benign enlargement of prostate, andlifting heavyweights are aggravating factors for epistaxis. Leech infestation may be a cause of unilateral epistaxis in those living in rural areas in rare circumstances. In most patients, no identifiable cause isfound, and the epistaxis is labelled as Idiopathic. 

Nosebleeds are common in young children due to their habit of nose picking, and hence keeping nails short is important. Diabetes may also contribute to epistaxis as it causesdegenerative changes in blood vessels and makes them fragile. Nasal bleed is frequentlyencountered in contact sports like football. Epistaxis may be anterior or posterior, depending on the site. The former is easily controlled and found frequently in children and young adults. The latter occurs predominantly in the elderly and is difficult to control as the site is difficultto access.
Epistaxis may be unilateral or bilateral. Sometimes the blood may pass into the throat and be swallowed. This may lead to hematemesis (vomiting of blood) and melaena (passage of blacktarry stools). Bleeding may be intermittent or continuous. 

Management includes resuscitatingthe patient, establishing the site of bleed, stopping the bleed and treatment of the underlyingcause. Investigations routinely done include complete blood count, random blood sugar, blood grouping and coagulation profile. Measures to control epistaxis range from applying local pressure to performing surgery.

Gentle direct pressure in the form of a nose pinch is sufficient in many cases of mild bleeding. Patient should lean forward to avoid swallowing the blood and breathe through the mouth. Anice pack placed on the bridge of the nose is further helpful. Nasal drops (topicaldecongestants) and ointments prevent further episodes. Bleeding not controlled by this, needcautery and nasal packing. Cautery (burning) of the bleed is done using chemicals (silver nitrate) or heat (electrocautery). Nasal packing is done if bleeding continues despite cautery. It can be placed anteriorly, posteriorly or both. Anterior nasal packing can be done with nasaltampon (sponge) or ribbon gauge. Posterior packing can be done with a balloon, a Foley catheteror gauze pad. Surgical measures include septal surgery to correct septal deviations andendoscopic ligation (tying off) of bleeding vessels. Other measures include angiographicembolization, laser and fibrin glue.

One of the primary settings for paediatric epistaxis is schools, especially in winters and teachers who are the initial responders should be aware of the correct first aid protocols. Simple solutions like tilting the head forward and applying digital compression to the soft part of the nose for 10 minutes can effectively manage most cases. In serious cases, active participation by teachers can keep children calm and safe until professional help arrives. Awareness among teachers builds confidence, and training on first aid leads to competence. Equipping teachers with first aid skills can ensure child safety in all emergencies, including epistaxis. 

To conclude, Epistaxis is a medical emergency that can be easily managed, provided thepatient or caregiver is aware of the first aid measures and the health care provider follows a systemicapproach.

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