Epistaxis (nasal hemorrhage) can often be stopped with cautery (sealing off a blood vessel using current or chemicals).
Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis may be treated with digital compression by applying firm sustained compression of the lower one third of the nose for 15 full minutes. Pressure can be applied by the treating clinician or by patients and caregivers under the direction of the clinician. An alternative to digital compression is the use of a commercial nose clip, if available. Applying local vasoconstrictors to the nasal cavity can be a useful adjunct to digital nasal compression.
If pinching is unsuccessful and the bleeding site is accessible and can be localized on anterior rhinoscopy, the next step is to control anterior epistaxis using cautery, which avoids some disadvantages of nasal packing (eg, discomfort, risk of infection, migration of packing material).
If bleeding continues from an unidentified anterior site despite use of nasal compression and cautery, nasal packing is required.
If bleeding is seen in the posterior pharynx but not in the anterior nasal passage, a posterior epistaxis should be considered. Posterior epistaxis is managed differently from anterior epistaxis, so identifying the site of bleeding is important whenever possible.
(See also Epistaxis and Clinical Practice Guideline: Nosebleed [Epistaxis].)
Indications for Treating Anterior Epistaxis With Cautery
Anterior nasal bleeding from a clearly visible site
Failure of nasal compression to stop nasal bleeding
Anterior bleeding sites are usually apparent on direct examination. If no site is apparent and there have been only 1 or 2 minor nosebleeds, no further examination is needed. If bleeding is continuing or recurrent and no site is seen, it may be necessary to use an anterior nasal packing method.
Contraindications to Treating Anterior Epistaxis With Cautery
Absolute contraindications
Inability to see the source of bleeding
Procedures described here are intended for epistaxis that is spontaneous or resulting from minor trauma. Epistaxis in patients with significant facial trauma should be managed by a specialist.
Relative contraindications
Patients with a pacemaker and/or defibrillator may require cardiology consultation before doing monopolar electrocauterization.
Patients with a cochlear implant may not be able to undergo monopolar electrocauterization.
Complications of Treating Anterior Epistaxis With Cautery
Injury or perforation of the nasal septum, particularly from multiple, overly aggressive or bilateral attempts at cauterization
Intranasal adhesions
Equipment for Treating Anterior Epistaxis With Cautery
Gloves, mask, and gown
Gown or drapes for patient
Suction source and Frazier-tip and/or other suction-tip suction catheters
Sterile gauze sponges
Emesis basin
Chair with headrest or an ear, nose, and throat (ENT) specialist's chair
Light source and head mirror or headlamp with adjustable narrow beam
Nasal speculum
Tongue depressors
Frazier-tip suction catheter
Cotton swabs or pledgets
Additional Considerations for Treating Anterior Epistaxis With Cautery
Ask about use of anticoagulant or antiplatelet drugs.
Check complete blood count (CBC), prothrombin time (PT), and partial thromboplastin time (PTT) if there are symptoms or signs of a bleeding disorder or the patient has severe or recurrent epistaxis.
Relevant Anatomy for Treating Anterior Epistaxis With Cautery
Kiesselbach's plexus is a vascular watershed area on the anterior nasal septum that is the most common site of anterior epistaxis.
Positioning for Treating Anterior Epistaxis With Cautery
The patient should sit upright in the sniffing position with the head extended, preferably in an ENT specialist's chair. The patient's occiput should be supported to prevent sudden backward movement. The patient's nose should ideally be level with the physician's eyes.
The patient should hold the emesis basin to collect any continued bleeding or emesis (eg, of swallowed blood).
Step-by-Step Description of Treating Anterior Epistaxis With Cautery
Have the patient gently blow the nose to remove clots, or suction the nasal passageway carefully.
Insert a nasal speculum with your index finger resting against the patient's nose and the handle parallel to the floor (so the blades open vertically).
Slowly open the speculum and examine the nose using a bright headlamp or head mirror, leaving one hand free to manipulate suction or an instrument.
Use a Frazier-tip suction catheter to remove any blood and clots obscuring the view.
Look for blood flowing from the anterior septum in the area of Kiesselbach's plexus, and look for blood flowing from the back of the nose.
Leave the topical drugs in place for 10 to 15 minutes to stop or reduce the bleeding, provide anesthesia, and reduce mucosal swelling.
If using electrocautery, place the tip of the instrument on the area of bleeding mucosa and apply coagulation current for a few seconds until charred mucosa is visible. If using thermal cautery, place the heated tip of the device on the area of bleeding for several seconds until the mucosa is charred. Protracted duration of cautery, application of cautery over a wide area, or bilateral use of cautery on the nasal septum can result in tissue injury including septal necrosis with resultant perforation. Other risks include infection and scarring.
If cautery has not stopped the bleeding after 2 attempts, another technique, such as a nasal packing, should be used.
Aftercare for Treating Anterior Epistaxis With Cautery
The cauterized area should be coated with petroleum jelly 2 to 3 times a day for 3 to 5 days.
Warnings and Common Errors When Treating Anterior Epistaxis With Cautery
Do not open the nasal speculum laterally or use the nasal speculum in an unsupported manner. (Brace a finger of the hand holding the speculum on the patient's cheek or nose.)
Do not cauterize the nasal septum bilaterally because doing so increases the risk of septal injury and perforation.
Tips and Tricks for Treating Anterior Epistaxis With Cautery
Elevating the patient's chair to eye height is easier on the practitioner's back than bending down.
Reinspect the nasal cavity 10 to 15 minutes after completion of cauterization to ascertain that bleeding has not restarted.
