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Managing nosebleeds

GP Dr Alex Watson and ENT consultant Mr Peter Robb advise on first-aid measures for active bleeding

GP Dr Alex Watson and ENT consultant Mr Peter Robb advise on first-aid measures for active bleeding

Advise patients to compress the soft part of the nostril tightly against the nasal septum. Sit the patient upright and lean forward over a bowl or sink, so not to swallow blood. Apply a cold compress to the forehead/nape of the neck – this produces vasoconstriction which may aid haemostasis). A useful compress is a bag of frozen peas.

Be aware that some patients may have lost a significant amount of blood before consulting you. Look for signs of shock – such as pallor/sweating – and measurement of pulse and blood pressure are important.

If you suspect significant blood loss, or first aid measures have failed, consider the insertion of an intravenous line starting a suitable plasma expander, together with immediate referral to A&E for specialist ENT assessment and treatment.

Once the epistaxis has stopped it is often possible to see the site of the bleeding. If there is an obvious site noted anteriorly this may be dealt with by cauterisation – either with silver nitrate chemical cautery or with electrocautery – after anaesthetising the nasal mucosa with a lignocane and vasoconstrictor solution on cotton wool.

Cream and cautery

In small children with minor recurrent nosebleeds, where no serious cause has been identified, antiseptic nasal carrier cream or silver nitrate chemical cautery, appear to be of similar effectiveness. Although some children find the smell and taste of antiseptic cream unpleasant, most find cautery painful despite use of local anaesthesia.

It would seem appropriate, therefore, to use antiseptic nasal cream as a first-line treatment. It has been suggested that four weeks' treatment may be required. This

period of treatment is non-licensed.

Nasal packaging may be required if there is continued haemorrhage with no clear bleeding point. Impregnated ribbon gauze (Bismuth Iodoform Paraffin Paste, BIPP) has been traditionally used. In the A&E or GP setting, nasal tampons – such as Merocel – are often effective as a first-line management.

If bleeding continues despite an anterior pack then it is likely that bleeding is coming from the posterior part of the nose and a postnasal pack or nasal balloon or catheter may be needed

In a few cases, bleeding will continue despite all the above measures and a formal examination under anaesthetic +/- arterial ligation should be considered. Arterial embol- isation performed by an interventional radiologist is an alternative to arterial ligation.

This is an extract from ENT in Primary Care by consultant ENT surgeon Mr Peter Robb and Surrey GP Dr Alex Watson, published by Rila. To order go to www.rila.co.uk or call 020 7637 3544

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