Canadian Pharmacists Journal - May/June 2019 - 167

PRACTiCeTOOL
to manage a nosebleed.13 Following receipt of verbal and written information specific to the management of epistaxis, this improved to 50% being
able to list at least 3 appropriate measures. Patients
with multiple risk factors for epistaxis, recurrent
epistaxis or those who take antithrombotic agents
should be provided with appropriate information for self-management of epistaxis (see "How
to manage a nosebleed" infographic). Among all
patients amenable to community-based care, a
staged approach to epistaxis management should
be incorporated that consists of 1) implementing
general measures, 2) using products available in
the community-based setting that either halt or
prevent subsequent episodes of epistaxis and 3)
an awareness of measures accessible only within
a hospital setting that may be necessary for those
with severe epistaxis.
General measures
In the event of epistaxis, patients should be
encouraged to take a seated position and remain
calm. The anterior aspect of the nose (below the
bony bridge) should be pinched continuously
for 15 to 20 minutes, resulting in compression
of the anterior nasal blood vessels.5,14 This is
contrary to the misconception that one should
apply pressure on the bony bridge of the nose,
wherein compression of blood vessels will not
occur. The head should not be tilted backwards
and instead should be positioned slightly forward to avoid pooling of blood in the pharynx,
which could result in nausea, aspiration, swallowing of blood or airway obstruction.5,15 If
bleeding is successfully stopped using the above
measures, irritation of the nasal mucosa (e.g.,
nose picking and blowing) should be avoided for
a few hours while the mucosa heals14,15; otherwise, a clot may be dislodged, resulting in recurrent bleeding. For this same reason, patients
should not try to pack their nostrils with tissues
or dry cotton balls, as eventual removal is likely
to disturb any clots that have formed. If bleeding is noticeably reduced following the above
steps, it is reasonable to repeat another 15 to
20 minutes of continuous compression. Bleeding
refractory to manual compression may be amenable to pharmacologic treatments (see below)
or may require emergency care centre assessment for possible invasive treatment measures,
especially if bleeding is profuse.3,5,14 Epistaxis
associated with head injury should be immediately referred to the ER.
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 

Products for use in the community setting
Numerous products have been used to manage
epistaxis (Table 2).16-25 Their role in management
is dependent upon the mechanism of action in
relation to the underlying cause of epistaxis.
Products containing moisturizing agents may
serve to mitigate further epistaxis providing dryness is problematic, whereas products that induce
a local vasoconstrictor effect or assist in clot stabilization (e.g., antifibrinolytics) offer temporary
approaches to halt bleeding yet may not prevent
the recurrence of epistaxis, depending on the
underlying etiology and subsequent treatment
of epistaxis. A practice tool outlining a suggested
treatment approach for community-based management of patients with epistaxis is provided in
Figure 2. Below is a summary of available data
assessing the use of these products. Data are limited and there is currently no evidence to suggest
superiority of one agent over another.
Unmedicated and medicated local moisturizers.
Regardless of a medicinal ingredient, these
products have vehicles that are moisturizing in
nature, affording benefit to those with dry nares.
Saline nasal gel for the prevention of recurrent
epistaxis has only been studied in a cohort of
74 anticoagulated patients (mean international
normalized ratio [INR] 2.4) for the prevention
of recurrent anterior epistaxis.16 Ninety-three
percent of patients had resolution of their
chronic epistaxis after 3 months of saline gel
use. However, it is unclear how patients used
the gel (including frequency and technique) or if
any adjunct treatment or preventative strategies
were employed. Given the benign risk profile, it
is reasonable to recommend liberal use of saline
gel for any patient at risk for or experiencing
recurrent epistaxis, particularly if nasal dryness
is an underlying risk factor. Of note, saline nasal
sprays or irrigations have not been studied in
patients with epistaxis and are not expected to
confer the same moisturizing effects that a gel
provides; in fact, saline solution may irritate
the nasal mucosa, thereby exacerbating the risk
for epistaxis.26 Thought to work by a similar
mechanism of hydrating the nasal mucosa, the
use of triamcinolone 0.025% cream applied
once weekly to the nares along with daily topical
petroleum jelly has been studied in patients
with recurrent mild anterior epistaxis (criteria
for "mild" epistaxis not provided).17 Although
there was no control group for comparison,
167



Canadian Pharmacists Journal - May/June 2019

Table of Contents for the Digital Edition of Canadian Pharmacists Journal - May/June 2019

Regulation and innovation in practice – Not a “drug interaction”?
Dietary sodium and the health of Canadians
Professional abstinence: What does it mean for pharmacists?
Canada’s new Healthy Eating Strategy: Implications for health care professionals and a call to action
Report from the 2018 National Summit on Wicked Problems in Community Pharmacy
Medical abortion: A practice tool for pharmacists
Community-based management of epistaxis: Who bloody knows?
The pharmacist’s role in successful deprescribing through hospital medication reconciliation
Pharmacists to improve hypertension management: Guideline concordance from North America to Europe
The patient experience in a community pharmacy mental illness and addictions program
Community pharmacists’ experiences with the Saskatchewan Medication Assessment Program
Cross-Canada updates
The conference experience—Making it yours
Canadian Pharmacists Journal - May/June 2019 - Intro
Canadian Pharmacists Journal - May/June 2019 - Cover1
Canadian Pharmacists Journal - May/June 2019 - Cover2
Canadian Pharmacists Journal - May/June 2019 - 137
Canadian Pharmacists Journal - May/June 2019 - 138
Canadian Pharmacists Journal - May/June 2019 - 139
Canadian Pharmacists Journal - May/June 2019 - 140
Canadian Pharmacists Journal - May/June 2019 - 141
Canadian Pharmacists Journal - May/June 2019 - 142
Canadian Pharmacists Journal - May/June 2019 - Regulation and innovation in practice – Not a “drug interaction”?
Canadian Pharmacists Journal - May/June 2019 - 144
Canadian Pharmacists Journal - May/June 2019 - 145
Canadian Pharmacists Journal - May/June 2019 - 146
Canadian Pharmacists Journal - May/June 2019 - Dietary sodium and the health of Canadians
Canadian Pharmacists Journal - May/June 2019 - Professional abstinence: What does it mean for pharmacists?
Canadian Pharmacists Journal - May/June 2019 - 149
Canadian Pharmacists Journal - May/June 2019 - 150
Canadian Pharmacists Journal - May/June 2019 - Canada’s new Healthy Eating Strategy: Implications for health care professionals and a call to action
Canadian Pharmacists Journal - May/June 2019 - 152
Canadian Pharmacists Journal - May/June 2019 - 153
Canadian Pharmacists Journal - May/June 2019 - 154
Canadian Pharmacists Journal - May/June 2019 - 155
Canadian Pharmacists Journal - May/June 2019 - 156
Canadian Pharmacists Journal - May/June 2019 - 157
Canadian Pharmacists Journal - May/June 2019 - Report from the 2018 National Summit on Wicked Problems in Community Pharmacy
Canadian Pharmacists Journal - May/June 2019 - 159
Canadian Pharmacists Journal - May/June 2019 - Medical abortion: A practice tool for pharmacists
Canadian Pharmacists Journal - May/June 2019 - 161
Canadian Pharmacists Journal - May/June 2019 - 162
Canadian Pharmacists Journal - May/June 2019 - 163
Canadian Pharmacists Journal - May/June 2019 - Community-based management of epistaxis: Who bloody knows?
Canadian Pharmacists Journal - May/June 2019 - 165
Canadian Pharmacists Journal - May/June 2019 - 166
Canadian Pharmacists Journal - May/June 2019 - 167
Canadian Pharmacists Journal - May/June 2019 - 168
Canadian Pharmacists Journal - May/June 2019 - 169
Canadian Pharmacists Journal - May/June 2019 - 170
Canadian Pharmacists Journal - May/June 2019 - 171
Canadian Pharmacists Journal - May/June 2019 - 172
Canadian Pharmacists Journal - May/June 2019 - 173
Canadian Pharmacists Journal - May/June 2019 - 174
Canadian Pharmacists Journal - May/June 2019 - 175
Canadian Pharmacists Journal - May/June 2019 - 176
Canadian Pharmacists Journal - May/June 2019 - The pharmacist’s role in successful deprescribing through hospital medication reconciliation
Canadian Pharmacists Journal - May/June 2019 - 178
Canadian Pharmacists Journal - May/June 2019 - 179
Canadian Pharmacists Journal - May/June 2019 - Pharmacists to improve hypertension management: Guideline concordance from North America to Europe
Canadian Pharmacists Journal - May/June 2019 - 181
Canadian Pharmacists Journal - May/June 2019 - 182
Canadian Pharmacists Journal - May/June 2019 - 183
Canadian Pharmacists Journal - May/June 2019 - 184
Canadian Pharmacists Journal - May/June 2019 - 185
Canadian Pharmacists Journal - May/June 2019 - The patient experience in a community pharmacy mental illness and addictions program
Canadian Pharmacists Journal - May/June 2019 - 187
Canadian Pharmacists Journal - May/June 2019 - 188
Canadian Pharmacists Journal - May/June 2019 - 189
Canadian Pharmacists Journal - May/June 2019 - 190
Canadian Pharmacists Journal - May/June 2019 - 191
Canadian Pharmacists Journal - May/June 2019 - 192
Canadian Pharmacists Journal - May/June 2019 - Community pharmacists’ experiences with the Saskatchewan Medication Assessment Program
Canadian Pharmacists Journal - May/June 2019 - 194
Canadian Pharmacists Journal - May/June 2019 - 195
Canadian Pharmacists Journal - May/June 2019 - 196
Canadian Pharmacists Journal - May/June 2019 - 197
Canadian Pharmacists Journal - May/June 2019 - 198
Canadian Pharmacists Journal - May/June 2019 - 199
Canadian Pharmacists Journal - May/June 2019 - 200
Canadian Pharmacists Journal - May/June 2019 - 201
Canadian Pharmacists Journal - May/June 2019 - 202
Canadian Pharmacists Journal - May/June 2019 - 203
Canadian Pharmacists Journal - May/June 2019 - Cross-Canada updates
Canadian Pharmacists Journal - May/June 2019 - 205
Canadian Pharmacists Journal - May/June 2019 - 206
Canadian Pharmacists Journal - May/June 2019 - The conference experience—Making it yours
Canadian Pharmacists Journal - May/June 2019 - 208
Canadian Pharmacists Journal - May/June 2019 - 209
Canadian Pharmacists Journal - May/June 2019 - 210
Canadian Pharmacists Journal - May/June 2019 - 211
Canadian Pharmacists Journal - May/June 2019 - 212
Canadian Pharmacists Journal - May/June 2019 - Cover3
Canadian Pharmacists Journal - May/June 2019 - Cover4
Canadian Pharmacists Journal - May/June 2019 - CPH1
Canadian Pharmacists Journal - May/June 2019 - CPH2
Canadian Pharmacists Journal - May/June 2019 - CPH3
Canadian Pharmacists Journal - May/June 2019 - CPH4
Canadian Pharmacists Journal - May/June 2019 - CPH5
Canadian Pharmacists Journal - May/June 2019 - CPH6
Canadian Pharmacists Journal - May/June 2019 - CPH7
Canadian Pharmacists Journal - May/June 2019 - CPH8
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_december2020
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https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_october2020
https://www.nxtbook.com/nxtbooks/sage/fai_202009
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_august2020
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_june2020
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_april2020
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_february2020
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_december2019
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_october2019
https://www.nxtbook.com/nxtbooks/sage/fai_201909
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_july2019
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_june2019
https://www.nxtbook.com/nxtbooks/sage/canadianpharmacistsjournal_05062019
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_april2019
https://www.nxtbook.com/nxtbooks/sage/sri_supplement_201903
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_february2019
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_december2018
https://www.nxtbook.com/nxtbooks/sage/tec_20180810
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_october2018
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_julyaugust2018
https://www.nxtbook.com/nxtbooks/sage/fai_201807
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_june2018
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_april2018
https://www.nxtbook.com/nxtbooks/sage/sri_supplement_201803
https://www.nxtbook.com/nxtbooks/sage/slas_discovery_201712
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_february2018
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_december2017
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_november2017
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_october2017
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_september2017
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_julyaugust2017
https://www.nxtbook.com/nxtbooks/sage/fai_supplement_201709
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_june2017
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_may2017
https://www.nxtbook.com/nxtbooks/sage/fai_201706
https://www.nxtbook.com/nxtbooks/sage/fai_201607
https://www.nxtbookmedia.com