Canadian Pharmacists Journal - May/June 2019 - 164

840380
research-article2019

CPHXXX10.1177/1715163519840380C P J / R P CC P J / R P C

PRACTICE TOOL  PeeR-ReViewed

PRACTICE TOOL * PEER-REVIEWED

Community-based management of
epistaxis: Who bloody knows?
Jenna Smith, BScPharm, ACPR; Jennifer Hanson, BSc Pharm, ACPR;
Raiyan Chowdhury, MD, FRCSC; Tammy J. Bungard, BSP, PharmD

Background

© The Author(s) 2019
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DOI:10.1177/1715163519840380
164



Epistaxis occurs commonly in the general population, with most people experiencing at least 1
episode in a lifetime. The age of patients most
affected by epistaxis follows a bimodal distribution, with the highest rates in those less than 10
years of age as well as those 70 years and older.1
Epistaxis is also commonly observed in clinical
practice among patients taking antithrombotic
therapies. As numerous cases are self-limiting
and do not require patients to seek medical
attention, the true incidence is likely not known.
In an American study over a 10-year period, epistaxis was responsible for 1 in 200 emergency
room (ER) visits, 6% of which required hospitalization.1 Hospitalizations for epistaxis may incur
significant costs, with a reported average hospital length of stay (LOS) of 3.24 days, resulting in
costs totalling from $6,000 to $17,000 depending on the treatment strategy used.2 However,
many cases of epistaxis may be safely managed
in the community,3 and providing patients with
education on general measures for management
and product options may mitigate the need for
hospital-based care. In this context, community-based health care practitioners are the first
points of contact. In order for practitioners to
provide appropriate advice to these patients,
it is necessary to have an understanding of the
etiology, risk factors and appropriate outpatient
treatment strategies for managing epistaxis. As
such, our purpose is to provide an overview of
community-based management of epistaxis,
with a practice tool for health care providers
outlining a suggested approach to management
in this setting, along with an educational infographic for patients. The treatment of epistaxis

in children or in patients with hereditary hemorrhagic telangiectasia is beyond the scope of our
review and will not be addressed here.

Nasal anatomy

The septum, which laterally divides the nasal
cavity, is lined with a mucosal membrane rich
in vascular supply.4 Blood supply and vasculature of the nasal cavity is complex. Epistaxis can
be classified as posterior or anterior, based on
the location of the affected blood vessel (Figure
1).3 Ninety percent of cases of epistaxis are identified as anterior epistaxis.5 The source of anterior epistaxis is most commonly the Kiesselbach
plexus (also known as "Little's area"6), which is
located on the anteroinferior region of the nasal
septum. Anterior epistaxis is typically self-limiting; however, if medical treatment is required,
the source of the bleed is often easily visualized
(provided the necessary equipment and knowledge of nasal anatomy are available), which
allows for the successful use of localized treatment strategies. In contrast, posterior epistaxis
arises from the posterior nasal cavity due to
bleeding directly from the sphenopalatine arteries.3 Posterior bleeds may also rarely originate
from the internal carotid artery itself, resulting
in life-threatening hemorrhage.7 Posterior epistaxis often results in anterior blood flow and
may not be as readily identified as in anterior
epistaxis. Given this, patients with posterior
epistaxis may have symptoms that include nausea, hematemesis, anemia, hemoptysis, melena
or hypotension.3 The source of bleeding in posterior epistaxis often cannot be adequately visualized without endoscopy and is therefore more
challenging to treat.4
C P J / R P C  *  M ay / J u n e  2 0 1 9  *  V O L  1 5 2 ,  N O  3
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Canadian Pharmacists Journal - May/June 2019

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