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Three Part Question

In [adults with spontaneous epistaxis in the acute care setting], are [topical vasoconstrictors] useful in the [control of bleeding]?

Clinical Scenario

A 64 year old patient with a history of epistaxis presents to the emergency department with a 3 hours history of spontaneous epistaxis. Simple first aid measures have been ineffective, and nor has the application of ice. You wonder whether there is any evidence base behind the use of topical vasoconstrictors or decongestants in the management of adult patients with epistaxis.

Search Strategy

Medline 1946 - May 2015 week 3 using OVID interface.

((exp vasoconstrictor) AND ((exp epistaxis) OR (exp nose AND bleed)))

Search Outcome

7 papers of which 2 are relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Krempl et al 1995 United States	60 adult patients who presented to the emergency department with ongoing epistaxis had their charts reviewed following discharge.	Retrospective Cohort Study	Arresting bleeding within 30 minutes with oxymetazoline alone	39 patients (65%)	Small study group. No control group with first aid alone for comparison was looked at. Short follow up period to assess the reoccurence of epistaxis.
			Arresting bleeding within 30 minutes with oxymetazoline and cautery	11 patients (18%)
			Rebleeding within 5 days	1 patient returned from the group treated with oxymetazoline solely
Bende M, Pipkorn U July 1990 Sweden	Adult patients presenting with ongoing posterior epistaxis to an ENT-clinic were treated with either terlipressin gel or placebo gel	Double-blind Randomised Controlled trial	Bleeding arrested within 45 minutes, and not recurring in the next 4 hours	39% in Terlipressin group vs. 62% in placebo group (p=0.23, n.s)	Small study May not be relevant to Ed as posterior epistaxis only, and based in ENT clinic, not emergency department. No evidence of sample size or power calculation. Trend towards placebo. Half of the paper looks at the effect of Terlipressin on normal mucosal blood flow in patients without epistaxis.

Comment(s)

Very limited evidence, with underpowered studies and no large RCTs. Poor evidence for topical vasoconstrictors for use in the Emergency Department, and studies mainly look at its use in the outpatient ENT setting. There is evidence for the use of intranasal vasoconstrictors to prevent epistaxis in patients who are to be nasally intubated, but little exists to demonstrate its use in the actively bleeding patient.

Clinical Bottom Line

Insufficient evidence, and more robust randomised controlled trials needed to provide a higher level of evidence before this treatment can be proven to be beneficial to patients with spontaneous epistaxis in the emergency department.

References

1. Krempl GA, Noorily AD Use of Oxymetazoline in the Management of Epistaxis The Annals of otology, rhinology, and laryngology, vol. 104, no. 9 Pt 1, p. 704-706, 0003-4894 (September 1995)
2. Bende M Pipkorn U Topical Terlipressin (Glypressin) Gel Reduces Nasal Mucosal Blood Flow but Leaves Ongoing Nose-bleeding Unaffected Acta Oto-Laryngologica 50% of patients stopped overall, which may be due to the presence of gel as opposed to any active in