Épistaxis : introduction et prise en charge

Epistaxis occurs when small, distended blood vessels in the nasal mucous membrane rupture. Common causes include trauma, low humidity, upper respiratory tract infections, allergies, foreign bodies, inhalation of corticosteroids or illicit drugs, overuse of decongestant sprays, nasal surgery, and anatomic malformation. High blood pressure, tumors, and systemic infections may also trigger nosebleeds.

Position the patient in a sitting posture, leaning slightly forward with the head tilted forward. This positioning prevents swallowing and aspiration of blood into the airway. Maintaining this upright position is the first critical step in managing epistaxis before applying direct pressure or administering medications.

Apply direct pressure by pinching the nose's soft outer portion against the midline septum continuously for 5 to 10 minutes. If ineffective, administer nasal decongestants such as phenylephrine, which act as vasoconstrictors to reduce bleeding. These initial measures control most anterior nosebleeds without requiring further intervention.

Nasal packing is the preferred treatment for posterior nasal septum bleeds when initial measures fail. Compressed nasal sponges or epistaxis balloons are inserted into the nares and advanced along the nasal cavity floor. As sponges absorb moisture, they expand to fill the cavity and provide hemostasis, typically remaining in place for 3 to 4 days.

For severe bleeding with visible bleeding sites, chemical cauterization using silver nitrate or thermal cauterization may be applied. Absorbable materials such as oxidized cellulose or gelatin-thrombin combinations can also be applied as supplemental patches to promote clotting and protect the nasal mucosa from further injury.

Advise patients to avoid forceful nose blowing, straining, intense exercise, nose picking, and smoking. Patients should refrain from vigorous exercise for several days and avoid hot or spicy foods that cause vasodilation. Ensure adequate nasal humidification and moisturize the nose with petroleum jelly to prevent dryness and rebleeding.

Patients with posterior packing should be placed in a monitored unit due to increased risk of complications. Vigilantly monitor level of consciousness, heart rate, rhythm, respiratory rate, and oxygen saturation using pulse oximetry. Observe for signs of breathing or swallowing difficulties. Antibiotics may be prescribed to prevent iatrogenic rhinosinusitis and sepsis, similar to management approaches used in acute pharyngitis.