Continuing Education Activity

Among the nasal emergencies, epistaxis is one of the most common chief complaints in patients presenting to the emergency department. Typically, anterior epistaxis is a benign event that is most often self-limited after the application of direct pressure. Children and the elderly are the most common populations affected, presenting with epistaxis secondary to either direct trauma via nose picking, friable mucosa, or anticoagulant use. This activity reviews the indications and contraindications of anterior nasal packing and highlights the role of the interprofessional team in the management of patients with epistaxis.

Objectives:

• Describe the indications for an anterior nasal pack.
• Explain how to place an anterior nasal pack.
• Review the contraindications to an anterior nasal pack.
• Outline a structured, interprofessional team approach to provide effective care to and appropriate surveillance of patients with nasal epistaxis.

Introduction

Among the nasal emergencies, epistaxis is one of the most common chief complaints in patients presenting to the emergency department. Typically, anterior epistaxis is a benign event that is most often self-limited after the application of direct pressure. Children and the elderly are the most common population affected, presenting with epistaxis secondary to either direct trauma via nose picking, friable mucosa, and anticoagulant use, respectively. Generally, anterior epistaxis is more common in the winter months in all age groups secondary to air from heating systems drying out the nasal mucosa, thus making it more prone to irritation and bleeding. If the direct application of pressure for approximately fifteen to twenty minutes fails, there are other methods available to achieve hemostasis. Vasoconstrictive agents and silver nitrate cautery may be useful. If epistaxis remains unresolved at that stage, anterior nasal packing may be necessary.

Anatomy and Physiology

In anterior epistaxis, the arterial blood supply most commonly implicated as the cause of the acute bleeding is Kesselbach plexus located in the Kesselbach triangle; this is also frequently referred to as the Little’s area. This area is part of the nasal septum (anteroinferior) above the vestibule. The Kesselbach plexus is made up of the anterior ethmoidal branch from the ophthalmic artery, the sphenopalatine branch from the maxillary artery, the superior labial branch from the facial artery, and the greater palatine branch from the maxillary artery.

Indications

In the emergency department, nasal packing for anterior epistaxis is indicated for bleeding that has not resolved after the application of direct pressure, vasoconstrictive medications, and cautery. Other indications for anterior nasal packing includes after surgical procedures by otolaryngology and oral maxillofacial surgery as well as after minor surgical procedures in the office. [1][2]

Contraindications

In the emergency department, nasal packing for anterior epistaxis is contraindicated in the following situations: 

• Significant facial/nasal bone fractures
• Basilar skull fracture
• Hemodynamic instability or airway compromise requiring emergency blood transfusion or intubation (relative)
  • Once stabilized, anterior nasal packing is permissible

Equipment

Anterior nasal packing will require the following equipment and materials:

• A hospital bed that has a back that can be positioned to 90 degrees
• Headlamp
• Otoscope
• Suction canister with either wall suction or portable suction
• Frazier suction tip
• Yankauer suction tip
• Nasal speculum
• Bayonet forceps
• Tongue depressor
• 4x4 inch gauze
• 2x2 inch gauze
• Dental roll
• Sterile lubricant
• Antibiotic ointment
• Intranasal vasoconstrictor
• Topical anesthetic
• Nasal tampon or intra-nasal device
• Personal protective equipment:
  • Goggles
  • Face mask
  • Gown
  • Gloves

Personnel

The technique requires medical professionals, such as physicians, physician assistants, and nurse practitioners that have training in the anterior nasal packing technique.

Preparation

If the patient is actively bleeding from the nose and hemodynamically stable with a patent airway, the first step is to attempt hemostasis via vasoconstriction agents such as cocaine, lidocaine with epinephrine, and/or oxymetazoline. Next, instruct the patient to manually hold pressure or place a nasal clip to hold pressure for approximately fifteen minutes. If bleeding persists, place the patient in a “sniffing” position, which can be accomplished while sitting straight up, flexing the neck and extending the head. Using a nasal speculum, examine bilateral nares. If a large clot is present, ask the patient to blow their nose to dislodge all clots allowing for a complete examination. If a discrete area of bleeding is visualized, attempt cautery with silver nitrate. When cauterizing, it is advisable that the mucosa immediately adjacent to the bleeding undergoes cauterization in a circle around the bleeding. If cautery fails, it is time to consider anterior nasal packing.

Technique

Previously, anterior nasal packing was accomplished using a petrolatum gauze that was inserted using bayonet forceps into the affected naris like an accordion to maximize the surface area that the gauze would cover and to fully tamponade the bleeding. This method has fallen out of favor with the advent of ready-made nasal packing devices. Nasal packs are available made out of polyvinyl alcohol (PVA) in the shape of a nasal tampon with a string at the base that expands when it comes in contact with moisture and is available in a variety of sizes. Some devices are made of expandable foam that comes inside an applicator shaped as a nasal tampon that expands when coming in contact with moisture. The foam is in an expandable balloon that is layered with carboxymethylcellulose (CMC) that serves a double purpose of applying direct pressure as well as platelet aggregation as a function of the CMC once it comes into contact with a liquid. Initial steps for nasal packing with any of the agents are nearly identical[3][4][5][6][2]:

• Depending on the device selected, soak in water for 30 seconds.
• Achieve anesthesia via vasoconstrictive agents (e.g. cocaine 4%, lidocaine 1 to 4% with epinephrine 1 per 100000, or oxymetazoline 0.05%).
• Generously coat either antibiotic ointment or petroleum jelly onto the tampon.
• Insert tampon into affected naris by applying quick, steady pressure directed along the floor of the nose, which is parallel to the ground (be cautious not to insert in the superior direction).
• Once inserted, the packing will likely already have started expanding secondary to contact with blood. However, injecting approximately 10 mL of normal saline or oxymetazoline 0.05% or tranexamic acid (TXA) will expand the tampon and may help in achieving hemostasis.
• Based on manufacturer recommendations, inflate the balloon using a 20mL syringe filled with air.
• Monitor the patient for another ten to thirty minutes to ensure that hemostasis is achieved.
• The packing will likely turn pink, which is normally secondary to a bit of oozing. If the patient continues to have active bleeding turning the packing bright red, or blood visualized dripping out past the packing, or if the patient is still swallowing blood, consider packing to have failed and moved on to further intervention.

From the emergency department, the patient is discharged and directed to follow up with the otolaryngologist in 24 to 48 hours for reassessment. Prior to discharge, a course of oral antibiotics may be prescribed as prophylaxis as the packing is considered a nidus for infection. There is no strong evidence to suggest that antibiotics help prevent infections such as sinusitis or toxic shock syndrome, and are therefore not considered a standard of care practice, but are a provider-dependent practice.[7] Anterior packs typically remain inserted for a minimum of 24 hours to achieve appropriate hemostasis. If removed too early, the rebleeding risk is greatly increased. Nasal packing removal is typically performed in the otolaryngology office but may be removed in the emergency department if the patient is unable to follow up with a specialist within 24 to 48 hours.

Patients who are anticoagulated or who take antiplatelet medications pose a unique challenge in achieving hemostasis. It is more challenging to obtain hemostasis, and they often have a tendency to rebleed even at 72 hours follow up. While emergency department providers can ultimately treat most of these cases, occasionally, it is necessary to consult the otolaryngology department or interventional radiology for further management. In the emergency department, typically additional attempts to cauterize bleeding, or repacking the naris with the addition of tranexamic acid results in successful hemostasis.[8] 

Complications

Following are the most commonly observed complications of anterior nasal packing: [9][10][11][12][13]

• Pain with insertion
• Pain with removal
• Rebleeding with removal
• Failure of hemostasis
• Degradation or necrosis of nasal mucosa
• Infection, particularly sinusitis
• Toxic shock syndrome
• Packing migration
• Aspiration

Clinical Significance

Although anterior epistaxis is typically self-limited, it can be frightening to patients and caregivers. Patients often present with a high degree of anxiety. The algorithm for treatment is important for the emergency medicine provider to be proficient in and comfortable with to perform it quickly and successfully. Being familiar with the equipment available at the facility is also important as there are small differences in products and materials that can render the procedure effective.

Enhancing Healthcare Team Outcomes

Treatment of epistaxis is critical to emergency medicine providers. Cases of anterior epistaxis are treatable with an algorithmic approach that emergency medicine providers, whether they be physicians, nurse practitioners, or physician assistants. All providers need to be familiar with the evaluation and treatment of epistaxis and competent performing anterior nasal packing. A strong working partnership between the otolaryngologists and the emergency department providers is necessary for providing specialty back up for the emergency department staff if they are unable to stop the epistaxis. Additionally, having a strong working relationship may facilitate appropriate follow-up in the office in 24 to 48 hours.