Myth Buster Episode 2 Hypertension and Epistaxis

Not infrequently we will see patients who present to the ED with a nose bleed. The usual measures will be employed (pressure, ice packs, packing, tampons), and then someone really clever notices that the blood pressure is elevated. All manner of blood pressure lowering drugs are then employed - GTN, labetelol, metoprolol, to name but a few, in order to reduce the blood pressure, and therefore reduce the pressure on that standing column of blood that connects the heart to the Kiesselbach's plexus. We've gone from permissive hypotension (penetrating trauma) to "active hypotension" for epistaxis.

The hypertensive emergencies include:

- hypertensive encephalopathy

- intracranial haemorrhage (including SAH)

- aortic dissection

- acute pulmonary oedema

- acute kidney injury

- pre-eclampsia

Not a hypertensive emergency

- epistaxis

I would love to know who the first person was, that suggested that giving blood pressure lowering drugs to patients who are acutely externally haemorrhaging is somehow a good idea. In my experience, standing in front of a patient actively hosing from their nose, holding a Rapid Rhino is more than enough to get their pressure up.

Studies conducted over the years have largely debunked the connection between epistaxis and hypertension (see links below), however, pockets of resistance still remain.

Eur Arch Otorhinolaryngol. 2011 Dec;268(12):1749-53. Epub 2011 Jun 9.

Blood Press. 2003;12(3):145-8.

Int J Cardiol. 2009 May 29;134(3):e107-9. Epub 2008 May 21.

Update on Monday, December 19, 2011 at 7:17PM by Amit Maini

A great summary of epistaxis, including all the anatomy, pathophys, and management can be found on LITFL by Kane Guthrie. Click Here to have a look...