Guest Speaker Dr. Shubhi Singh
Tag Archives: epistaxis
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
- Have patient blow their nose to clear all clots
- Visualize nasal cavity and oropharynx now and with each reassessment for source of bleeding. Don’t forget to wear mask and use a headlamp
- Soak cotton balls or pledgets in lidocaine with epinephrine and 500mg of tranexamic acid
- Pack nose with soaked cotton and replace clamp for 10 mins
2. Cauterize
- Remove clamp and packing
- Area should be well blanched and anesthetized
- Visualize plexus and cauterize proximal to bleeding area for 10 sec max AND never both sides of septum (higher risk of septal perforation)
- 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
- Apply unilateral nasal packing (Rapid Rhino, Merocel, etc)
- Reassess in 10 mins, visualizing oropharynx for continued bleeding
- 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.
- 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.
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
ED Rounds – Epistaxis
ED Rounds – March 2018
Dr Christopher Chin MD FRCSC
Rhinology, Anterior Skull Base, Head and Neck Oncology
Otolaryngology- Head & Neck Surgery
Saint John Regional Hospital
Objectives
- Cover basic and advanced techniques to obtain hemostasis in the ER
- Review what options are available if that fails
Agenda
- Review of anatomy
- Management algorithm
- What options are available when traditional packing fails
- What’s new in epistaxis?
- Special scenarios
EM Reflections – February 2018
Thanks to Dr. Paul Page for leading the discussions this month
Edited by Dr David Lewis
Top tips from this month’s rounds:
Pleuritic Chest Pain – Don’t forget the Abdomen
Headache – Not always Migraine
Epistaxis – Posterior Bleed
CME QUIZ
Pleuritic Chest Pain – Don’t forget the Abdomen
The commonest causes of pleuritic chest pain (pleurisy) presenting to the ED include:
- Pulmonary embolus
- Pneumonia
- Pericarditis
- Myocardial infarct
- Pneumothorax
Once these have been ruled out consider the following differential diagnosis:
ref: American Family Physician (May 2007)
Another differential to consider is:
Perforated peptic ulcer
This can result in localized sub-diaphragmatic peritonitis that can result in pleuritic chest pain
Tips:
- If a CT Chest has been performed – look for free air under the diaphragm
- Always document an abdominal exam when assessing a patient with pleuritic chest pain
- Although radiologists are highly skilled, like any physician, they are not infallible. Conservative estimates suggest an error rate of 4%. See this excellent article: The Epidemiology of Error in Radiology and Strategies for Error Reduction
- Wherever possible physicians should always review the images from CT and X-Ray prior to reading the formal radiology report.
Arrows depicting free air on erect CXR – note the double stomach bubble sign on the left
Free air seen on lower slice of CT Chest. Easily mistaken for bowel
Headache – Not always migraine
The commonest cause of headache presenting to the ED is migraine
The features of migraine headache are well documented in this article – The diagnosis and treatment of chronic migraine
The differential diagnosis for patients presenting with headache is large. This excellent website (https://ddxof.com/) provides algorithms to help consider the differential diagnosis in the cardinal EM presentations.
From: DDxof.com
Another differential to consider is:
Anemia
Sub-acute onset anemia secondary to chronic blood loss e.g menorrhagia, chronic GI bleed, etc can present with fatigue, visual disturbance and headache.
Tips:
- Patients who present to ED with a new headache (no previous hx of primary headache syndrome or change in symptoms) should have baseline investigations including CBC and Glucose.
- Always review the paramedic and triage notes for supplementary information and the presence of additional symptoms that may broaden or narrow the differential.
- Patient ethnicity and skin colour may mask the presence of anemia.
Epistaxis – Posterior Bleed
Posterior epistaxis is a difficult condition to manage and is associated with a number of acute and serious complications. In this study, 3.7% required intubation.
The #FOAM Blog post provides an excellent outline to the management of posterior epistaxis – EMDocs.net
Posterior Nasal Packing – video
Tips:
- All cases of major bleeding, including epistaxis should be initially managed in the highest acuity areas of the ED. Patients can then be rapidly stepped down and relocated to lower acuity areas if determined to be lower risk after initial assessment.
- Consider using a suction device to aid intubation in cases of massive obscuring oro/naso-pharynx haemorrhage.
PulmCrit: Large-bore suction for intubation: strategies & devices
CME QUIZ
EM Reflections - Feb 18 - CME Quiz
EM Reflections – Nov 17 – CME Quiz