Epistaxis Management in the ED – 3 Step Method

Epistaxis Management

Resident Clinical Pearl (RCP) – December 2018

Luke Taylor R3 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. Kavish Chandra

 

It’s 0300 and you are on a solo night shift when a 76 year old male with blood dripping out of both nares is brought into an examining room. It looks a little more profuse than what you saw on Stranger Things last month, but you are also wondering how to best tackle this very common emergency problem

 

History

-Laterality, duration, frequency

-Estimated blood loss, presence of any clots?

-Inciting factors such as trauma or coagulopathy

-Past medical history, especially hypertension, clotting disorder, HHT

-Medications such as anticoagulants or anti-platelets

 

Physical examination

-Have patient blow nose or use suction to clear clots

-Do not try and visualize until decongestion complete

-Visualize with nasal speculum for site of bleeding. If an anterior bleed, most commonly the bleeding site will be Little’s area (Figure 1)

-See below for management if patient’s ABCs stable. If unstable be prepared to secure airway and call for help – ENT/interventional radiology

 

Figure 1. Nasal vascular anatomy, adapted from https://www.juniordentist.com/what-is-littles-area-or-kiesselbachs-area-and-the-arteries-in-it.html.

 

Management

-Get IV access, draw CBC and coagulation profile when indicated

-Treat as unstable until proven otherwise

 

Pearls

  • Apply ice to the hard palate (popsicles, ice in the mouth) to reduce nasal blood flow up to 25%
  • TXA in patients on anti-platelets (primarily aspirin) results in faster cessation of bleeding
  • Ducanto suction in future -> SALAD technique – Ducanto-bougie intubation for large bleeds
  • Only reverse anticoagulants if absolutely necessary – “local problem, local solution”

 

Three Step Approach to Epistaxis

1. Visualize and decongest

  1. Have patient blow their nose to clear all clots
  2. Visualize nasal cavity and oropharynx now and with each reassessment for source of bleeding. Don’t forget to wear mask and use a headlamp
  3. Soak cotton balls or pledgets in lidocaine with epinephrine and 500mg of tranexamic acid
  4. Pack nose with soaked cotton and replace clamp for 10 mins

2. Cauterize

  1. Remove clamp and packing
  2. Area should be well blanched and anesthetized
  3. Visualize plexus and cauterize proximal to bleeding area for 10 sec max AND never both sides of septum (higher risk of septal perforation)
  4. If successful and bleeding ceases on reassessment, apply surgicel wrapped around a small piece of surgifoam to create a “dissolvable sandwich”and discharge home

3. Tamponade

  1. Apply unilateral nasal packing (Rapid Rhino, Merocel, etc)
  2. Reassess in 10 mins, visualizing oropharynx for continued bleeding
  3. If stops, can discharge home with packing in place and follow up in ED or ENT clinic in 48hrs for removal. No antibiotics required in immunocompetent patients.
  4. If continues to bleed, move the patient to a higher acuity area and apply bilateral nasal packs

When to call ENT

If bilateral nasal packing bleeding continues, assume posterior bleed and initiate resuscitation, draw labs (CBC, coagulation profile, cross-match if not already done). Reverse known coagulopathy and consult for OR or embolization.

 

ED Rounds – Epistaxis

 

 

References:

Dr Christopher Chin and his informative talk

http://rebelem.com/topical-txa-in-epistaxis/

https://emergencymedicinecases.com/ent-emergencies/ 

https://lifeinthefastlane.com/epistaxis/

 

This post was copyedited by Kavish Chandra @kavishpchandra

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Pharyngitis

“Doc, you gotta’ help me”: corticosteroids as an adjuvant for pharyngitis

Resident Clinical Pearl – December 2015

Kavish Chandra, R1 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by: Dr Matt Greer and Dr David Lewis

Pharyngitis is a common presenting complaint in the EDs and primary care practices. The etiology of pharyngitis most commonly is viral in origin (rhinovirus, coronavirus and adenovirus); however, other infectious etiologies include bacteria, fungi and parasites.1 Of the bacterial causes, group A beta-hemolytic Streptococcus (GABHS) is the most common pathogen, representing 15% of pharyngitis cases in adults and 15 to 30% in children (1).

 stst2

 

There are several treatment algorithms for the treatment of GABHS, and varying treatments for the other etiologies of pharyngitis. While physicians often assume that patients are seeking antibiotics for the treatment of their pharyngitis, a major treatment goal for patients is to improve their pain and swallowing.2 Some advocate for the addition of a single dose of dexamethasone in moderate to severe cases, which may shorten the duration of pain (2).

 

The Question:

How effective are corticosteroids as an adjuvant in the treatment of pharyngitis?

A Cochrane review in 2012 looked 8 randomized-controlled trials which included 743 adult and pediatric patients with tonsillitis, pharyngitis, sore throat and/or odynophagia treated with either corticosteroids or placebo (3). The meta-analysis included out-patients in the ED or in primary care practices and excluded in-patients, patients with infectious mononucleosis, post-surgery or peritonsillar abscesses. Primary outcomes were: resolution of pain and mean time to onset of pain relief. Corticosteroids included betamethasone (8mg), dexamethasone (up to 10mg) or prednisone (60mg), and were administered either orally or intramuscularly. All patients received antibiotics and other analgesia. In addition to antibiotics and analgesia, the administration of corticosteroids increased the likelihood of complete pain resolution at 24 hours by 3.2 times and by 1.7 times at 48 hours, NNT of 3.3 and 3.7 respectively. The administration of corticosteroids reduced the mean time to onset of pain relief by 6 hours and 14.4 hours for complete pain resolution. There were no differences in adverse effects in the corticosteroid and placebo groups.

 

Limitations of the review: all patients were treated with an antibiotic and analgesia in addition to a corticosteroid in the treatment arm. Therefore, studies are needed to assess the effectiveness of corticosteroids as stand-alone therapy. Two trials included only children, and because of the small number of participants in each RCT, there was high heterogeneity and inconsistent results in that group of patients. The meta-analysis was also underpowered to detect adverse effects; however, the short courses of corticosteroids are unlikely to be harmful.

 

Bottom Line:

In conjunction with antibiotic therapy, corticosteroids can reduce pain and decrease time to complete resolution of pain in patients with pharyngitis.

 

References

  1. Cline, D. (2013). Infections and disorders of the neck and upper airway. (3rd ed.) Tintinalli’s emergency medicine: Just the facts (pages 550-555). New York: McGraw-Hill.
  1. Korb, K., Scherer, M., & Chenot, J. F. (2010). Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: A systematic review. Annals of Family Medicine, 8(1), 58-63. http://www.annfammed.org/content/8/1/58.full.pdf+html
  1. Hayward, G., Thompson, M. J., Perera, R., Glasziou, P. P., Del Mar, C. B., & Heneghan, C. J. (2012). Corticosteroids as standalone or add-on treatment for sore throat. The Cochrane Database of Systematic Reviews, 10, CD008268. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008268.pub2/pdf

 

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