A 19 year-old patient presents to your ED with a nosebleed. His friend states they were in the bleacher seats of an anime convention when he became so aroused that his nose just started gushing blood. He’s been bleeding for about 30 minutes despite holding pressure on his nose. Vitals are normal. When you try to examine his nose and remove the tissues, blood starts oozing from his nostrils.
90% of epistaxis is anterior, arising from Keisselbach’s plexus. Caused by: digital trauma (yeah that’s you, nosepicker!), rhinosinusitis/dry mucosa/ excessive nose-blowing, uncontrolled hypertension, coagulopathy, etc.
Treatment:
1. Direct pressure, inspection for a site of bleeding. If seen, try to apply topical vasoconstrictors such as phenylephrine or oxymetazoline. If you see the exact site of bleeding and vasoconstrictors have not worked, consider chemical cautery with topical silver nitrate; however, this is only advised if you have direct visualization and a relatively bloodless field. Never attempt chemical cautery in both nares.
2. If the above does not work, time to go for gold with tampons, aka anterior nasal packing. Nasal tampons like the RhinoRocket are available in our ED. Nothing will make this 19 year-old kid feel more cool and special than shoving a tampon up his nose.
You try to control his bleeding with nasal packing, but blood continues to ooze down his pharynx. Where might the blood be coming from now? How are you going to control it and treat him?
Posterior epistaxis! Usually arising from the sphenopalatine artery. This is much more difficult to control. Now you should involve ENT. Posterior packing involves a 12-14 Fr foley. First, use local anesthetic, lubricate with bacitracin, and then insert and inflate with 5cc, retract until gently lodged in place, then inflate with another 5-10cc. ENT uses more advanced and definitive methods like EMA embolization, endoscopic cautery, or surgery to stop the bleed.
What is your dispo for a patient with anterior nasal packing?
Your board answer: discharge with antibiotics to protect against staph infection and toxic shock syndrome (amox-clav is the first choice). HOWEVER, the available evidence does not support the routine use of antibiotics for anterior nasal packing. Regardless, patients with anterior packing must follow up with an ENT specialist in 2-3 days, and many ENT docs still prescribe antibiotics despite the lack of supporting evidence.
What is your dispo for a posterior bleed? What are the complications and what must you closely monitor for?
Admission. Posterior packing can lead to pressure necrosis, infections, dyspnea or hypoxia, and cardiac dysrhythmias so they must get admitted to a cardiac tele-monitored bed. It is recommended that these patients be given antibiotics during admission.
Trivia time! What does having a nosebleed imply in Japanese culture?
Sexual arousement. Yup, nothing shows your more hot and aroused than…. a nosebleed?! Typically portrayed in manga or anime as a guy who sees an attractive girl and has an explosive nosebleed. Wanna see for yourself?
References
EM Lyceum. “Epistaxis, Answers” Post from Oct 12, 2013. http://emlyceum.com/2013/10/12/epistaxis-answers/
Huge thanks to Dr. deSouza.
Remember, the boards and in-service exam are not always evidence-based. What we do in practice may not always be the right answer on your test. Frustrating, I know, but keep your chin up! Unless you have a nosebleed…
Kylie Birnbaum
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4 Comments
edenkim · March 14, 2016 at 10:28 am
I love that you know about the nosebleed thing! You are so Asian
iandesouza · April 10, 2016 at 4:42 pm
Nice post. It will not be on your tests, but consider soaking your packing with TXA:
A new and rapid method for epistaxis treatment using injectable form of tranexamic
acid topically: a randomized controlled trial. American Journal of Emergency Medicine 31 (2013) 1389–1392
http://dx.doi.org/10.1016/j.ajem.2013.06.043
Hope Taitt · July 4, 2017 at 8:46 pm
Identification of posterior nosebleeds are best made after correct packing of the nose. An anterior bleed will stop, but a posterior bleed will keep on briskly bleeding. Management of posterior epistaxis includes calling ENT, then proceeding to stop the bleeding via insertion of a balloon catheter or Foley catheter. In both procedures, a topical anesthetic and topical vasoconstrictor are used. With a balloon catheter, the catheter is advanced until it is in the naris and then the posterior balloon gets inflated with 10mL of sterile water. The posterior balloon is retracted until it rests on the choana and the anterior balloon gets inflated with 30mL of sterile water (or less)based on the patients comfort. A foley catheter (10-14 French) works similarly except there is only one balloon that initially gets inflated with 5 mL of water until retracted into the correct position and another 5-10 mL of water is added.
tdouglas11 · July 6, 2017 at 5:12 pm
Something to consider with management of posterior bleeds using the Foley tampenade or other packing techniques that we discussed in CBL at conference this week was a vagal response. Not only can you see cardiac arrhythmias as mentioned in the post, but also bradycardia and hypoventilation. Just another reason to make sure to admit these patients to tele beds for monitoring!