Case of the Month – February 2017

A 34 year-old male with no past medical history presents with 3 days of intermittent epistaxis. The bleeds have been light for the past few days consisting of mostly a few blood streaks on the tissue. This current bleed however, has lasted nearly 20 minutes and has been a steady flow of brighter colored blood. He has tried to hold pressure for 10-20 minutes, but as he eases up the bleeding starts again. He denies lightheadedness, dizziness, chest pain, palpitations, or shortness of breath. He has never experiences prolonged bleeding episodes and denies any recent skin changes. He has otherwise been in good health and denies any weight changes, headaches, photophobia, cough, coryza, abdominal pain, nausea, vomiting, diarrhea or constipation. He has no family history of bleeding disorders and no recent travel.

PSH: None
Allergies: Seasonal
Medications: OTC antihistamines PRN
Social: No drugs, alcohol or tobacco

PE: Tm: 98.6, HR: 96, RR: 18, BP: 126/78
GEN: Lying in bed, well-dressed, and comfortable
HEENT: Crusting of blood at nares bilaterally; nasal septum midline; active venous bleeding; unable to visualize any active blood vessel
PULM: Breathing comfortably, speaking full sentences; clear to auscultation bilaterally
CV: Tachycardia, regular rate and rhythm
ABD: Normal bowel sounds, soft, non-tender, non-distended; no rebound or guarding
Ext: No cyanosis, clubbing, or edema

Labs:
Na: 140, K: 4.2, Cl: 99, Bicarb: 22, BUN: 21, Cr: 0.96, Glucose: 125
Protein: 6.5, Albumin: 3.49, Calcium: 8.4, AST: 18, ALT: 4, Alk Phos: 158, Tbili: 1.6,
WBC: 11, Hb/Hct: 13.5/41, Plt: 144
PT: 9.3 PTT: 34 INR: 1.0
Lactate 1.8
ECG: Normal Sinus Rhythm

Just as you get back to your seat, the patient tells you he feels fine, but the bleeding has picked up again.

Are there any medications that might help stop the bleeding?
If you had to pack the nose, what would be your technique?
You have now packed the nose. Will you prescribe antibiotics?

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Steven Greenstein

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1 comment for “Case of the Month – February 2017

  1. eschnitz
    February 10, 2017 at 3:19 pm

    you could try using a lidocaine/epinephrine combination or a TXA soaked packing and leaving it for ten minutes. oxymetazoline spray can work as well. some use phenylephrine spray. I supposed you could use topical cocaine although only read about this and don’t know how the nurse or pharmacist would react to this order.
    there are different packing options depending on hospital formulary. i think most are placed in water prior to insertion along the floor and then have the ability to inflate a proximal (anterior bleed) and distal (posterior bleed). if one side does not control bleeding then the contralateral side can be packed as well.
    if bilateral packing does not work then ENT consult should probably be placed for likely posterior bleed and need for admission. I suppose in certain circumstances IR could embolize an arterial bleeder but I’d have ENT involved.

    as far as antibiotics, the evidence isn’t great but i believe most guidelines still recommend cephelexin, TMP/SMP or augmentin to prevent TSS. Check out what life in the fast lane says about medico-legal pitfalls. I will continue abx at the moment.

    anterior bleeds at 48 hour ENT f/u
    posterior are admitted for monitoring

    https://www.acep.org/Clinical—Practice-Management/Focus-On–Treatment-of-Epistaxis/

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553192/

    Zahed, Reza, Payman Moharamzadeh, Saeid Alizadeharasi, Asghar Ghasemi, and Morteza Saeedi. 2013. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. The American journal of emergency medicine, no. 9 (July 30). doi:10.1016/j.ajem.2013.06.043. http://www.ncbi.nlm.nih.gov/pubmed/23911102.

    http://rebelem.com/topical-tranexamic-acid-epistaxis-oral-bleeds/

    http://lifeinthefastlane.com/epistaxis/

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