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Three Part Question

In [adult patients presenting to the ED with acute epistaxis], is [the use of nasal clips as first aid] more effective than [manual compression of the nose].

Clinical Scenario

A 40-year-old patient presents to the ED with epistaxis. They are otherwise fit and well with no signs of bleeding elsewhere. You wonder if a nasal clip will deliver more effective first aid than manual compression.

Search Strategy

EMBASE (1974 to December 2024) and MEDLINE (1936 to December 2024) databases were searched utilising the Ovid interface and the following keyword strategy:

Epistaxis.mp. OR exp Epistaxis OR nosebleed$.mp. OR [exp *Nose OR nose.mp AND h?emorrhage.mp. OR bleed$.mp.] AND [(nose or nasal].mp. AND (clip?.mp. OR exp *clip/)]

No search filters were used, including language and date of publication. A supplementary search of the Cochrane database was conducted using the same search terms, in addition to the ‘Cited by’ function on Google Scholar. The citation lists of relevant papers were screened for any studies missed by our search paradigm.

Search Outcome

107 papers were identified using our search strategy, with sixteen duplicates. Eighty-three papers were excluded based on title and abstract review and six papers after full text review. Four papers were excluded because they were not relevant to our three-part question. Two papers were excluded because they were commentaries.

Two papers were retained for final analysis. This included a prospective randomised controlled trial (RCT) (1) and a retrospective chart review (2). All participants included in both studies presented to the emergency department with a primary diagnosis of epistaxis. Demographic data for the retrospective chart review was provided on a separate review article using the same patient cohort (3). The results are summarised in Table 1. Both authors were contacted to provide additional data but no response was received.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hajimaghsoudi et al 2018 Iran	Patients over 16 presenting to ED with active anterior epistaxis (N = 61) Manual compression group (n = 31) Nose clip group (n = 30) Mean age = 41	Prospective, single-centre randomised controlled trial	Length of stay in ED	Shorter length of stay (p < 0.005)	Small sample size. Patients not blinded to treatment allocation. No raw data provided for individual outcomes. Vague descriptions used for individual outcomes. Patients in “sniffing” position instead of sitting position with forward tilt as per NICE CKS. Did not specify the type of nasal clip used.
			Managing epistaxis	Better control, particularly in severe epistaxis (p = 0.008)
			Patient satisfaction (Likert scale)	Greater patient satisfaction (p < 0.005)
			ENT consultation + intervention	Less ENT consultation + intervention (p = 0.8)
			Successful cessation of epistaxis	66.7% (vs 35.5% in digital compression)
Newton et al 2016 Canada	All patients presenting to ED with primary diagnosis of anterior epistaxis (N = 17) Mean age = 72.3	Retrospective, single-centre observational study	Recurrence of epistaxis (ipsilateral recurrence within 14 days of initial treatment)	59% (n =10)	Small sample size. No indication on how long nasal clips were applied for. Reliant on potentially incomplete retrospective charting data. Bleeding severity not indicated. Selection bias - dependent on physician preference. Did not specify the type of nasal clip used.

Comment(s)

Simple first-aid measures resolve 70% of epistaxis cases (4). However, patients may struggle to maintain consistent and adequate pressure with manual compression, leading to variable outcomes (1). Manual compression involves patient cooperation and could pose a challenge for those with a range of physical and mental disabilities. The use of nasal clips has the potential to deliver standardised pressure on the appropriate part of the nose and can likely be applied by ED staff members with ease, alleviating the variability associated with manual techniques. It is a cost-effective intervention (3) that is simple to employ in practice with the potential of preventing further invasive interventions for patients. Our review supports the use of nasal clips for epistaxis first-aid. The RCT demonstrated that nasal clips were more likely to stop bleeding (particularly in severe epistaxis), was associated with greater satisfaction, and led to a shorter length of stay in hospital in comparison to manual compression. Although encouraging, these results should be interpreted with caution. The RCT (1) did not include any patients on anticoagulants. This is a problematic exclusion as many patients who present with epistaxis use these medications. The retrospective chart review (2) has 82.4% of patients on at least one anticoagulant or antiplatelet medication. Newton et al (2) found a statistically significant association between the use of anticoagulant medication and the recurrence of epistaxis (p=0.0119). This may account for the 59% recurrence rate of epistaxis in the nasal clip group reported by Newton et al. Although existing literature on this subject is limited, it is promising. Larger prospective studies are indicated in comparing the use of nasal clips to digital compression or a rescue therapy for failure, particularly measuring the length of stay in ED, success rate, recurrence rate and any unreported side effects.

Clinical Bottom Line

Nasal clips appear to be more effective than manual compression at delivering first aid for epistaxis. They may shorten length of ED stay and reduce further invasive interventions.

References

1. Hajimaghsoudi M, Largani HA, Baradaranfar MH, Aghabagheri M, Jafari MA, Saeedi M A novel method for epistaxis management: Randomized clinical trial comparing nose clip with manual compression American Journal of Emergency Medicine 2018; 36(1):149-50
2. Newton E, Lasso A, Petrcich W, Kilty SJ An outcomes analysis of anterior epistaxis management in the emergency department Journal of Otolaryngology - Head & Neck Surgery 2016;45:24
3. Nithianandan H, Thavorn K, Banaz F, Macdonald K, Lasso A, Kilty SJ Determining the hospital cost of anterior epistaxis treatment modalities at a Canadian tertiary care centre Journal of World Journal of Otolaryngology - Head and Neck Surgery 2019;5(4);193-199
4. Passali D, Damiani V, Passali FM, Tosca MA, Motta G, Ciprandi G. An International Survey on the pragmatic management of epistaxis Acta Biomedica 2020;91(1-S):5-10