How to manage recurrent epistaxis with recent prolonged episodes and low vitamin B12 levels?

Management of Recurrent Epistaxis with Recent Prolonged Episodes

For patients with recurrent epistaxis and recent prolonged episodes, the first-line management should include nasal compression followed by anterior rhinoscopy to identify the bleeding site, with subsequent targeted treatment such as chemical cautery or nasal packing if needed. 1

Initial Assessment and Management

Immediate Management

• Apply direct pressure to the nose for 5-10 minutes by pinching the soft part of the nose
• Have the patient lean slightly forward to avoid blood draining down the throat
• Apply ice packs to the bridge of the nose to promote vasoconstriction

Examination

• Perform anterior rhinoscopy to identify the bleeding site after removing any blood clots 1
• For recurrent nasal bleeding despite prior treatment, nasal endoscopy should be performed to identify the site of bleeding and guide further management 1, 2
• Look for common causes:
  • Dry nasal mucosa (most common)
  • Local trauma (including nose picking)
  • Thin nasal skin (as noted in this patient)
  • Vascular abnormalities

Treatment Options

First-line Treatments

1. Nasal compression: Apply pressure for at least 5 minutes 1
2. Topical vasoconstrictors: Oxymetazoline or phenylephrine can stop 65-75% of nosebleeds 3, 4
3. Chemical cautery:
   • Should be performed only after anesthetizing the bleeding site
   • Restrict application only to active or suspected bleeding sites
   • Avoid bilateral cautery to prevent septal perforation 1, 3

Second-line Treatments

1. Nasal packing:

   • For ongoing active bleeding where the site cannot be identified despite compression
   • Use resorbable packing for patients with suspected bleeding disorders 1
   • Educate patient about type of packing, removal plan, and warning signs 1

2. Tranexamic acid:

   • Topical tranexamic acid may be effective in stopping bleeding and reducing rebleeding risk 5, 6
   • Recent evidence suggests 1000mg dose is more effective than 500mg for topical application 6

Management of Recurrent Epistaxis

Prevention Strategies

• Nasal moisturization:

  • Saline nasal sprays
  • Petroleum jelly applied to the anterior septum
  • Humidification, especially during dry seasons 3

• Avoid triggers:

  • Discourage nose picking
  • Use gentle nose blowing techniques
  • Avoid intranasal drug use 3

Investigation of Underlying Causes

• Laboratory testing for recurrent cases:
  • Complete blood count (CBC) to evaluate for anemia and thrombocytopenia
  • Coagulation studies (PT/INR, aPTT)
  • Consider vitamin B12 levels (particularly relevant for this patient with known low B12) 3

Special Considerations for This Patient

• Low vitamin B12: Address this deficiency as it can contribute to poor tissue healing and fragile mucosa
• Thin nasal skin: Emphasize moisturization and gentle care
• Recent prolonged episode: Indicates need for more thorough evaluation and possibly more aggressive management

Follow-up and Monitoring

• Document outcome of intervention within 30 days 1
• Schedule follow-up examination to assess healing and effectiveness of interventions
• Educate patient on warning signs that require prompt reassessment:
  • Bleeding that doesn't stop after 15-20 minutes of compression
  • Recurrent episodes despite home management
  • Signs of significant blood loss 3

When to Refer to Specialist

• If bleeding persists despite first-line measures
• For recurrent unilateral epistaxis (may indicate underlying pathology)
• If nasal endoscopy is required but not available in primary care setting 1, 3

Remember that the goal of treatment is not just to stop the immediate bleeding but to prevent recurrence and identify any underlying causes that may require specific treatment.