What is the management for a persistent epistaxis (nose bleed) after trauma?

Management of Persistent Epistaxis After Trauma

For persistent epistaxis following trauma, apply firm sustained compression to the lower third of the nose for 10-15 minutes as first-line treatment, followed by vasoconstrictor spray and cauterization if a specific bleeding site can be identified. 1

Initial Management

1. Direct pressure technique:

   • Apply firm, sustained compression to the lower third of the nose for 10-15 minutes 1, 2
   • Ensure proper technique with patient leaning forward to prevent blood from flowing down the throat
   • This simple measure has high success rates when performed correctly

2. Vasoconstrictor application:

   • Apply oxymetazoline (Afrin) or similar nasal decongestant spray to constrict blood vessels
   • Success rate of 65-75% when used appropriately 1
   • Can be used in conjunction with direct pressure

Second-Line Interventions

If bleeding persists after initial measures:

1. Cauterization:

   • Preferred over nasal packing if a specific bleeding site can be identified 1
   • Electrocautery (especially bipolar) is more effective than chemical cautery
   • Should be performed under local anesthesia
   • Caution: Avoid excessive cautery to prevent septal damage

2. Nasal packing:

   • Indicated when bleeding cannot be controlled by other methods
   • Options include:
     • Non-absorbable materials
     • Absorbable materials
     • Newer hemostatic materials
   • Be aware of potential complications: infection risk, decreased blood flow, septal perforations, pressure sores, and worsening of obstructive sleep apnea 1

Management of Refractory Bleeding

For cases not responding to above measures:

1. Endoscopic arterial ligation:

   • Target the sphenopalatine artery (SPA)
   • Success rate of 97% compared to conventional nasal packing 1
   • May be necessary in severe post-traumatic cases as demonstrated in case reports 3

2. Embolization:

   • Consider for intractable cases
   • Success rate of approximately 80%
   • Higher risk of serious complications including stroke (0.9-1.6%) 1

Post-Treatment Care

• Nasal moisturization with saline gel or spray 1-3 times daily
• Humidification in dry environments
• Avoid digital trauma (nose picking) and vigorous nose blowing 1

Special Considerations for Trauma-Related Epistaxis

• Evaluate for associated injuries, as nasal fractures can be a sign of skull fracture, brain injury, or cervical spine impairment 2
• Posterior epistaxis is more common in trauma cases and may require more aggressive management 4
• Consider underlying factors that may contribute to persistent bleeding, such as coagulation disorders or vascular injuries 1, 4

When to Refer

Refer to otolaryngology or emergency department for:

• Posterior epistaxis
• Bleeding not controlled with anterior packing
• Recurrent epistaxis despite treatment
• Suspected underlying pathology requiring endoscopic evaluation 1

Warning Signs Requiring Immediate Attention

• Return of blood from nose or mouth
• Fever over 101°F
• Increasing pain
• Vision changes
• Shortness of breath
• Loss of color around the skin of the nose
• Swelling of the face
• Diffuse skin rash 1