Case of the Month 18: Refractory Epistaxis

In general, direct pressure handles most cases of epistaxis. However, sometimes medications are required. First-line agents are topical vasoconstrictors such as phenylephrine, oxymetazoline or epinephrine. These work by alpha-adrenergic receptor agonism in the nasal mucosa to reduce local congestion and intravascular pressure leading to less bleeding and better visualization of a culprit vessel. Interestingly, there is a Cochrane review studying topical application of tranexamic acid (TXA) and found a statistical reduction in blood transfusions; however, the studies used to form their analysis were largely from data in surgical patients and might not be able applicable to the regular ED population.[1]

The technique used to pack the nose depends on what you’re using to pack the nose. The nose can be packed with a tampon, gauze, or a balloon catheter.

The nasal tampon

First, position the patient sitting up with the head in the sniffing position. Then coat the tampon with bacitracin. This may lower the theoretical risk of toxic shock syndrome but more importantly acts as a lubricant and helps to place the tampon in the correct position. Generally, the tampon will expand from the moisture and blood in the nose; however, to expedite the process you can squirt 10cc of normal saline into the nostril. The tampon will absorb the solution and expand quicker.

Packing Gauze:

Again, position the patient with the head in the sniffing position. You will need special gauze made for packing. These are typically lined with petrolatum (eg, Xeroform) or bismuth subnitrate and iodoform paste (BIPP). Using forceps, advance the packing gauze into the nose. This can be a bit tricky and slightly uncomfortable for the patient. Grab the gauze about 7-10cm from the nose, and then using the forceps, advance the gauze into the nose. Keep repeating the procedure until the nose is tightly packed making sure to leave a 10cm tail at the end.

Balloon Catheter:

The technique for using a balloon catheter will depend on the source of the bleed and the manufacturer’s recommendations for the specific product used. The basic idea for anterior bleeds is to insert the first balloon and inflate the first balloon with either water or saline as recommended by the manufacturer. When you’re unable to visualize an anterior source, the bleed is brisk, the patient is older, bleeding is bilateral or not controlled with anterior packing, you should consider a posterior source[2]. Packing a posterior bleed is a bit more complicated. First insert the catheter deep into the nose. Inflate the posterior balloon and retract until you meet resistance as the balloon lodges in posterior choana. Once in place, inflate the anterior balloon with the amount of solution as recommended by the manufacturer.

If you find yourself in a situation where you don’t have a balloon catheter available, a simple alternative is a foley catheter. Coat a 10F-14F catheter with a petroleum-free lubricant. Advance the catheter until its slightly visible in the mouth. Then partially inflate the balloon and retract slowly and gently until the catheter is resting against the posterior choana. Fully inflate the balloon to the manufacturer recommended volume. If the patient experiences pain or there is distention of the soft palate, then deflate the balloon.

Due to the fear of toxic shock syndrome, many prescribe antibiotics after nasal packing. The evidence to support this practice is limited.[3] [4] [5] In 2013, Biggs et al[6] compared re-admissions rates using the old guidelines that recommended oral antibiotics and the new ones that did not. They found no difference in hospital readmissions. This study was limited by small sample size and may actually steer us towards a different clinical question. Perhaps, topical antibiotics alone are enough to prevent toxic shock syndrome, and future research should compare topical rather than oral antibiotics to control. A 2012 study[7] provides the clearest data to support withholding antibiotic prophylaxis after nasal packing. Given all these evidence, why do our ENT colleagues continue to ask us to prescribe antibiotics? Because, the level of evidence for OR against antibiotics is weak. The sample sizes are small and with toxic shock being so rare, it is unlikely that studies were powered enough to truly show an effect. And finally, after weighing the theoretical risk of toxic shock syndrome vs. real complications of antibiotics, it is unclear which poses a greater risk at the moment. Therefore more research needs to be done in this field, but for now, deciding to withhold antibiotics appears to be a very reasonable choice.