Managing nasal bleeding in OPD general practice is often challenging, time-consuming, & takes practice. Here are 11 tips to manage nasal bleeding in general practice that can help avoid common pitfalls, improve outcomes, and increase patient & physician satisfaction.

Epistaxis

Nasal bleeding or epistaxis management is often difficult, time-consuming, and labour-intensive. Epistaxis often leads to poor outcomes and repeat visits for rebleeding even in the best of conditions.

Even if it is now under control, epistaxis commonly returns if it generated enough blood to warrant medical attention (even without hemodynamic impairment). In patients under the age of 18, this is less true. In both groups, a thorough and in-depth investigation is necessary to determine if epistaxis is still present.

Pinching the nose is part of first aid to control epistaxis

Patient evaluation for epistaxis

Ask the following history:

• Laterality, length of time, and frequency
• Severity
• The amount of blood lost and any aggravating or precipitating variables
• Past medical history
• Current drugs
• Family history of bleeding disorders

A visual examination:

1. Pay attention to whether the bleeding is coming from the front or the back.
2. The visualisation will be aided by suctioning or blowing the nose to remove clogs, as well as by using topical vasoconstrictors or anaesthetics.
3. Spread the naris vertically and gently insert the nasal speculum. A decent light source will also be needed to help you see the bleeding spot.
4. The absence of an anterior source of bleeding, bleeding from both nares and the presence of blood in the posterior pharynx all point to a posterior cause of bleeding.

Tests:

1. Complete blood count: In case a transfusion is necessary, patients who are bleeding heavily should undergo a complete blood count to assess their haemoglobin level.
2. INR: Warfarin-taking patients should have their INR evaluated.
3. Coagulation tests: They should not be routinely performed on individuals who come with epistaxis; they are only beneficial in those with established coagulopathies or chronic liver diseases.
4. Other blood tests: These tests should only be requested if a patient's medical history justifies them e.g. LFT can be observed in patients with persistent alcohol misuse.
5. CT scan: Radiological examinations have a limited role in the medical care of epistaxis; nevertheless, a CT scan is recommended if a tumour is suspected and is usually scheduled after consulting with your ENT expert.

The following advice should assist you in avoiding frequent mistakes, enhancing results, and raising patient and physician satisfaction:

1. Protect yourself first by wearing a face shield and a gown. Patients who have nasal manipulation commonly cough or sneeze, which produces blood spray.
2. Get your gear ready in advance. Create a policy that has it put at the bedside when the patient is roomed by working with your nurses or technicians. A strong, precise light is necessary, preferably in the form of a headlamp so that both hands are free. 
3. Acute therapy is often not necessary for epistaxis, despite the fact that hypertension or high blood pressure might make it worse. Create a calm atmosphere, project confidence, and describe your plan of action before you begin to help your patient. These measures may often lower their blood pressure.
4. Ask your patient to blow their nose gently to eliminate any clots that may have developed since these obstructions not only hinder or block the absorption of drugs but also impair vision.
5. Maintain firm pressure with a clip or clamp for at least 15 minutes while you collect everything you need.
6. Vasoconstrictor/anaesthetic: Pack your chosen medicines and the way you want to give them (e.g., with cotton balls, pledgets, or swabs) tightly because they won't work as well if there isn't direct touch and pressure. Also aiding in tamponading any bleeding is tight packing. Given that the septum is movable, it may be required to pack both nasal chambers to provide sufficient tamponade.
7. When using the nasal speculum, keep your fingers away from the nasal septum. This might be a sensitive location where bleeding has most likely occurred. To provide the best possible visualisation with your high-intensity light, carefully enter the tip along the inner border of the ala, open the speculum, and then draw out with mild traction.
8. Ensure the field is dry, and the region is anaesthetised before employing silver nitrate to cauterise a friable area or visible vessel. This region is delicate, and chemical burns hurt. Minimise the number of repeated cautery efforts and apply mild pressure with a gently rolling motion.
9. Commercial nasal packing may be shortened and the tip can be trimmed at an angle if it is too big. To help ease insertion, apply a topical antibiotic ointment to the nasal tampon; this acts as both an antibiotic and a lubricant. In certain circumstances, placing a hemostatic within the nasal cavity or on the nasal tampon may be beneficial. To facilitate insertion and reduce discomfort, follow the shape and direction of the nasal tube. 
10. After inserting the packing, add 1-3 ccs of water or saline using a syringe (no needle). The packing might enlarge and soften as a result. Be ready for a little spitting, coughing, or leaking. If packing with an inflatable item, fill the balloon to the ideal size with air or the proper liquid.
11. After the procedure, monitor your patient to make sure the bleeding is still under control, they are tolerating the packing or balloon, and their vital signs are stable. Depending on the quantity of blood loss, the results, the procedure, and your patient's comorbidities, this might take 15 to 30 minutes (or more).
12. Call for assistance right away in cases where poor outcomes are more likely, such as hemodynamic compromise brought on by blood loss, hypoxia or acute cardiopulmonary distress, post-surgical epistaxis, bleeding tumours (especially those that have been exposed to radiation), patients who have underlying bleeding disorders, an inability to control the bleeding or other situations.

While waiting for the last set of vital signs before discharging the patient, you should complete the record and write your observations, the procedure, if the patient endured the procedure well, and any problems.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.