Overview of Anterior Epistaxis Nasal Pack
Epistaxis, also known as a nosebleed, is one of the most frequent types of emergencies related to the nose. Approximately 1.7 out of every 1,000 people will visit the emergency room for a nosebleed each year. Usually, a type of nosebleed called “anterior epistaxis” will stop on its own or by applying pressure to the nose. Children and older adults have nosebleeds most often, usually because of habits like picking their nose or inserting an object into it, delicate or easily bleeding nasal tissue, or taking blood-thinning medication, especially if they also have high blood pressure. In younger and middle-aged adults, another common cause of nosebleeds is the use of drugs inside the nose. These drugs can be ones prescribed by a doctor, like steroid nasal sprays, or illegal drugs, like cocaine.
In general, nosebleeds are more common in the winter for people of all ages. The warm air from heating systems can dry out the tissue inside the nose, making it more likely to get irritated and bleed. If pressing on the nose for 15-20 minutes doesn’t stop the bleeding, other treatments might be needed. These can include medicines that constrict the blood vessels in the nose or using silver nitrate to cauterize, or seal, the area that is bleeding. If the nosebleed still doesn’t stop, it might be necessary to use a nasal pack to put pressure on the bleeding area.
Anatomy and Physiology of Anterior Epistaxis Nasal Pack
The main source of blood supply to the front part of the nose, which is often linked to nosebleeds, is a group of blood vessels known as the Kiesselbach plexus. This network is on the lower part of the wall inside your nose (the septum), near the opening of your nostrils and can be seen during an examination of the front of your nose. This plexus is made up of arteries from multiple major blood vessels. These arteries supply blood to the lining of the nose and the bone and cartilage underneath.
More than 90% of nosebleeds happen in the front part of the nasal septum. However, severe nosebleeds can happen further back in the nose, which can be tougher to deal with. Usually, doctors will only consider it as the source after they have ruled out the front part as the source of bleeding. If the nosebleed is from the back of the nose, treating it may require a longer nasal pack and the person may need to be monitored for longer afterwards.
Nosebleeds from the back of the nose most often come from ending branches of a major facial artery. For nosebleeds from the veins in the back of your nose, they usually start from the Woodruff plexus, which is a network of veins on the side wall of your nasal cavity which is near the back of your nose.
Nosebleeds can happen not only due to physical injury but may also be a sign of underlying health issues that affect blood clotting or platelet function. Knowing and treating any underlying problem with the blood will make stopping the bleeding more successful. People can have nosebleeds for various non-injury reasons, which includes high blood pressure, low platelet count, a bleeding disorder, and the use of medicines like aspirin, chemotherapy or certain supplements, especially turmeric. Managing the blood pressure and adding fresh plasma or platelets can be the difference between a successful or unsuccessful attempt at stopping the nosebleed. In certain situations other treatments might be necessary, like giving vitamin K for an overdose of the blood-thinning drug warfarin or using a medicine called desmopressin for a condition called von Willebrand disease.
Why do People Need Anterior Epistaxis Nasal Pack
If your nose bleed (also known as anterior epistaxis) doesn’t stop after applying direct pressure, using certain drugs that narrow the blood vessels (vasoconstrictive medications), or a procedure that seals the bleeding area (cautery), you might be treated with nasal packing in the emergency room. Nasal packing is also sometimes used to help stop bleeding during or after operations.
When a Person Should Avoid Anterior Epistaxis Nasal Pack
In the emergency room, sometimes a treatment called nasal packing, which involves inserting material into the nose to stop a nosebleed, cannot be used in certain situations. For instance, if a person has a severe fracture at the base of their skull or significant facial or nose bones fractures, doctors wouldn’t use this method. People who are very unstable with signs like abnormal blood pressure or heart rate, requiring immediate blood transfusion, or have difficulty breathing needing tube insertion into the windpipe for help, may also not be suitable for this treatment. However, once these conditions are managed and the person becomes stable, doctors can go ahead and use nasal packing to manage a nosebleed.
Equipment used for Anterior Epistaxis Nasal Pack
If your doctor needs to pack the front part of your nose (a procedure known as anterior nasal packing), they’ll need various equipment and materials. Here’s what they might use:
- A hospital bed with an adjustable back that can be raised to a 90-degree standing position
- A headlamp to light up the treatment area
- An otoscope, a tool that allows the doctor to look inside your nose
- A suction canister (either wall-mounted or portable) to remove fluids
- Frazier and Yankauer or Goodhill suction tips, which are specific types of suction tips
- A nasal speculum, a tool used to widen the nostrils for examination
- Bayonet forceps, a kind of long plier used for grasping and holding objects
- A tongue depressor to hold the tongue down if needed
- 4×4 inch and 2×2 inch gauze to dress wounds or soak up fluids
- A dental roll, a piece of cotton used to control bleeding in the mouth or nose
- Sterile lubricant and antibiotic ointment to reduce friction and prevent infection
- Intranasal vasoconstrictor and Tranexamic acid, medications used to shrink the blood vessels and stop bleeding
- Topical anesthetic to numb your nose and make the procedure more comfortable
- A nasal tampon or similar device specifically designed for packing the nose
- Personal protective equipment such as goggles, a face mask, gown, and gloves to ensure the procedure is safe and hygienic.
Who is needed to perform Anterior Epistaxis Nasal Pack?
A doctor or a highly skilled healthcare professional can handle a procedure called anterior nasal packing. This process usually happens in a medical center when there’s an urgent or immediate need. Anterior nasal packing is a method used to stop nosebleeds. In severe situations, a nurse or a first aid worker can also perform this procedure. These individuals are well trained to handle such cases, ensuring the patient’s safety and comfort.
Preparing for Anterior Epistaxis Nasal Pack
If a person’s nose is actively bleeding, but they’re otherwise stable and breathing well, certain medications may be administered to help stop the bleeding. These can include medications like a 4% solution of cocaine, lidocaine (an anesthetic or numbing drug) with a small amount of epinephrine (a medication that constricts blood vessels), or a 0.05% dose of oxymetazoline (a decongestant that shrinks blood vessels). After administering these medications, the person should apply gentle pressure to the lower part of their nose for around 15-20 minutes.
Alternatively, a device known as a nasal clip can be used in the same area to apply consistent pressure. If the nose continues to bleed, the person needs to sit upright and lean their head forward slightly, a position that looks a bit like the person is about to sniff. The inside of the nostrils needs to be examined with a tool called a nasal speculum to find the exact point of bleeding. If there is a big clot inside the nostril, it should be removed to better see inside the nose.
If a specific area of bleeding is found, a process called cautery might be used. This involves applying silver nitrate to the bleeding spot to help stop the bleeding, but this might not be successful if the bleeding is severe. Electrocautery, which involves using a special tool to deliver heat to the bleeding spot, could be used if the normal cautery fails. If all else fails, nasal packing, which involves filling the nose with special materials to help stop the bleeding, should be considered.
How is Anterior Epistaxis Nasal Pack performed
In the past, if your nose was bleeding, doctors used to use a long piece of gauze to pack your nostril and stop the bleeding. This method isn’t used much anymore. Now, we use specially made nasal packing devices to do the job.
There are an array of nasal packing devices available. They look sort of like tampons with a string at the end, and come in different sizes for adults and children. Once these devices are inserted into the nostril, they expand once they get moisture and help apply pressure to stop the bleeding. If the nostril space is big, more than one may be used.
Another device we use to pack the nostril is an inflatable balloon. It is covered in a special substance that helps stop bleeding by applying direct pressure and helping the blood become sticky.
Generally, any form of nasal packing is done without the patient being asleep or sedated as it could prevent the basic protective reflexes from functioning properly.
Before nasal packing begins, we ensure that the patient is breathing properly and we use some sort of agent to numb the feeling. If we’re using nasal tampons, we may need to soak them in water before inserting them into the nostril. The insertion is done using gentle pressure along the floor of your nose. Once in, we can inject the tampon with a liquid to expand it further and stop the bleeding.
If we’re using the inflatable balloon device, we will coat it with antibiotic ointment or petroleum jelly, insert it into the nostril, and then inflate it with air. It’s important we use air because it’s less likely to cause damage.
After packing, we monitor for any signs of continued bleeding. If the device is absorbing blood and turning pink, that’s okay. If the device turns bright red, or blood is still dripping past it or you’re still swallowing blood 30-60 minutes later, that shows the packing has failed and further action will be required. If we need to, we may insert more devices into the same nostril, or potentially the other one. This must be done with care so as not to damage the septum (the wall separating your two nostrils).
If your nosebleed (or “anterior epistaxis” as we call it) can be successfully treated with nasal packing, you might be allowed to go home. You’ll need to see a specialist to reassess your condition in a few days though. Most of the time, the packing stays in your nostril for at least 24 hours. If it’s removed too soon, it’s more likely that your nose will start bleeding again. Doctors do this at an Ear, Nose and Throat (ENT) specialist’s office, but sometimes it can also be done at the emergency department.
Packing a bleeding nose can be rather trickier for people whose blood doesn’t clot easily. For these folks, we might use some different tactics. For instance, we may choose to use materials that absorb over time, like cellulose mesh or a sinusotomy absorbable nasal pack. While they might not stop the bleeding as effectively as the other stuff, they’re less likely to cause any injury as they don’t need to be removed.
Possible Complications of Anterior Epistaxis Nasal Pack
When packing the front of your nose to manage a nosebleed, you could experience some issues. The most common ones are pain when inserting or removing the pack, bleeding when the pack is removed, and the failure to stop the bleeding. In rare cases, some people might notice bloody tears, which is when blood mixes with tear fluid due to pressure changes in the nose. While distressing, it’s not a harmful complication.
Other issues can include damage or death of the surface tissue inside the nose, caused by the rubbing or pressure from the nasal pack. There’s also the risk of infections like sinusitis and toxic shock syndrome, and in rare cases, the packing could move or be breathed in.
If the pack is put into the back of your nose, it could disrupt your breathing and even slow down your heart due to the immediate pressure changes it can cause. This is why patients are usually monitored in the hospital when they have this type of packing. Too much pressure in this part of your nose could also damage the soft part of the roof of your mouth. To prevent this, your healthcare team will frequently check your condition.
What Else Should I Know About Anterior Epistaxis Nasal Pack?
Anterior epistaxis, or a nosebleed that comes from the front part of the nose, usually stops on its own. However, it can be scary for the person experiencing it and the people around them. This could lead to them feeling very anxious when they go to the hospital. So it’s crucial for emergency doctors to feel confident in their ability to stop the nosebleed quickly and effectively using a method called nasal packing.
Nasal packing involves putting a material into the nose to apply pressure to the blood vessel and stop the bleeding. Along with the skills to do this, it’s equally important that doctors are familiar with the tools they have on hand at their hospital. This is because different products or materials may be used a bit differently. Being prepared will help make sure the bleeding can be controlled as swiftly and effectively as possible.
