What are key considerations for patients with prolonged nasal bleeding (epistaxis) following traumatic injury?

From the Guidelines

Patients with prolonged epistaxis following trauma should be managed with a systematic approach, starting with first-line treatments such as nasal compression, vasoconstrictors, and nasal packing, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery Foundation 1. The initial steps in managing epistaxis include applying direct pressure to the anterior portion of the nose for 10-15 minutes while leaning forward to prevent blood from draining down the throat, as suggested by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. If bleeding persists, medical evaluation is necessary to identify the source and severity, and healthcare providers may use topical vasoconstrictors like oxymetazoline or phenylephrine sprays to constrict blood vessels, followed by examination with proper lighting and suction to locate the bleeding site. Some key considerations for patients with prolonged epistaxis following trauma include:

• Assessing for underlying conditions that may contribute to prolonged bleeding, such as hypertension, coagulopathies, or medication effects (particularly anticoagulants or antiplatelet drugs) 1
• Considering post-traumatic vascular injuries like pseudoaneurysms in cases of recurrent or severe bleeding 1
• Maintaining head elevation, avoiding strenuous activity, refraining from nose-blowing, and using saline nasal sprays to keep the nasal mucosa moist during recovery 1
• Prescribing antibiotics like amoxicillin-clavulanate (875/125 mg twice daily) when nasal packing remains in place to prevent toxic shock syndrome 1. It is also important to note that the management of epistaxis may vary depending on the severity and location of the bleeding, as well as the patient's underlying medical conditions, as highlighted in the clinical practice guideline: nosebleed (epistaxis) executive summary 1.

From the FDA Drug Label

Desmopressin acetate injection will also stop bleeding in hemophilia A patients with episodes of spontaneous or trauma-induced injuries such as hemarthroses, intramuscular hematomas or mucosal bleeding Desmopressin acetate injection will usually stop bleeding in mild to moderate von Willebrand’s patients with episodes of spontaneous or trauma-induced injuries such as hemarthroses, intramuscular hematomas or mucosal bleeding

For patients with prolonged epistaxis following trauma, key considerations include:

• The use of desmopressin acetate injection to stop bleeding in patients with hemophilia A or mild to moderate von Willebrand’s disease
• Monitoring of bleeding time and factor VIII coagulant activity, ristocetin cofactor activity, and von Willebrand factor antigen to ensure adequate levels are being achieved 2
• Caution in patients with severe classic von Willebrand’s disease or abnormal molecular form of factor VIII antigen, as desmopressin acetate injection is not indicated for these conditions.

From the Research

Key Considerations for Patients with Prolonged Epistaxis Following Trauma

• Assessment of airway, breathing, and circulation is crucial before identifying the bleeding source and achieving hemostasis 3
• Management options for epistaxis include topical vasoconstrictors, direct pressure, cautery, tranexamic acid, nasal tampons, Foley catheters, or surgical intervention 3
• Topical tranexamic acid has been shown to be more effective than topical oxymetazoline in achieving hemostasis in anterior epistaxis 4
• Oxymetazoline has been found to be superior to tranexamic acid and epinephrine-lidocaine in achieving rapid hemostasis and reducing recurrence in epistaxis 5

Patient Factors to Consider

• Older patients with comorbid conditions are more likely to undergo operative intervention and experience associated complications 6
• Cardiovascular and psychiatric comorbidities are more prevalent in patients who undergo operative intervention for epistaxis 6
• The management of epistaxis does not appear to have a significant impact on mortality risk 6

Treatment Approaches

• Identification of the actual bleeding point and treatment with chemical or electrocautery, bipolar diathermy, or small packs placed directly over the bleeding point is recommended for primary epistaxis 7
• Secondary epistaxis should be managed by identifying the cause and applying appropriate nasal therapy and corrective systemic medical management 7
• Patients with continued epistaxis despite initial measures should be considered for surgical ligation techniques or embolization earlier rather than later 7