EPISTAXIS

Question 1

MANAGEMENT

Answer 1

INITIAL MANAGEMENT

1. Position patient upright in sniffing position
2. Blow out clots from nose
3. Apply pressure against the septum in the lower 1/3 of the nose for 15 min
4. Consider adjunct intraoral ice
5. Physical Exam if Hemostasis Achieved

VASOCONSTRICTION / ANESTHETIZE

If refractory to pressure

1. INSERT COTTON PLEGET SOAKED IN:

VASOCONSTRICTOR:

Oxymetazoline 0.05%

OR

Phenylephrine 0.5%

OR

Epinephrine 1 mg / ml

OR

cocaine 4%

ANESTHETIC:

Lidocaine 1%-4% solution

2. REMOVE AFTER AFTER 10-15 MIN
3. Physical Exam if Hemostasis Achieved

CHEMICAL CAUTERIZATION

If refractory to vasoconsriction / anesthetization

1. Cauterize with silver nitrate in 4 quadrants around bleed.
2. Hold for 5-10 secs.
3. Never cauterize both sides of septum.
4. Do not repeat until 4-6 weeks after.
5. Physical Exam if Hemostasis Achieved

ANTERIOR NASAL PACKING

If refractory to cauterization

MEROCEL NASAL TAMPON:
1. Coat with bacitracin or mupirocin.
2. Insert along floor of nasal cavity.
3. Irrigate with water.+ Tranexamic Acid. 500 mg TXA applied to topical foam or anterior nasal packing.

RAPID RHINO:
Anterior epistaxis balloons soaked with water.
Inflate slowly until bleeding stops.

POSTERIOR NASAL PACKING

1. Posterior Nasal Balloon
   There are 2 ports
2. Foley Catheter
   Insert via nose until visible in the posterior oropharynx
   Inflate until baloon seen in OP
   Anterior traction until posterior vessels tamponade
   Secure to face
3. KEFLEX
   500 qid

INVESTIGATIONS

Routinely not indicated

CBC (HBG, platlets)
Lytes
Creat
LFTs
INR/PTT

DISPOSITION: DISCHARGE

Discharge after 1 hr observation

Do not to blow their nose for 7-10 days

Return to ER or Primary Care for removal within 24-48 hrs.

Irrigate prior to removal.

Discontinue NSAIDs 3-4 days

Question 2

DOCUMENTATION

Answer 2

HISTORY

1. HPI
   Laterality
   Duration
2. ASK ABOUT SEVERE BLEEDING
   Estimated quantity of blood
   Melena
   Hematemesis
   Pre Syncope
   Chest Pain
   Dyspnea
3. ASK ABOUT TRIGGERS:
   Trauma
   Foreign Body
   Drug use
   URTI / Rhinosinusitis
   Drying of nasal mucosa / change in weather
4. ASK ABOUT RELEVANT PMHx
   Prior Epistaxis
   Bleeding disorders
   HTN
   Liver dz
   Kidney dz
   Cardiopulmonary Disease
   Vascular Disorders
   COPD on home o2
   OSA on CPAP
   Nasal or sinus surgery
   Nasal malignancies
5. MEDS:
   Anticoagulation or antiplatelet agents
   Intranasal medication (intranasal steroid sprays)x`
6. SOCIAL:
   intranasal drug use (cocaine). Cigarette Smoke
   EtOH Use

PHYSICAL EXAM
1. BP:
HTN vs. HoTN

2. MATERIALS
   Lamp, Tongue Blade, Suction, PPE, Nasal Speculum
3. IDENTIFY LATERALITY
4. IDENTIFY POSTERIOR BLEED
   Bilateral Bleeding
   Bleeding Not resolved with pressure
   Blood in Posterior Oropharynx
   Suction OP while apply pressure to nose in sniffing position if equivocal
5. SPECULUM EXAM
   Once hemostasis is achived
   Examin nose with nasal speculum with bright head lamp.
   Open vertically i.e. the SAGITTAL plan

Question 3

DDx

Answer 3

Local
-Trauma (picking, trauma to face)
-Foreign body
-Smoking
-Blood thinners
-Illicit drugs
-Sinusitis
-Neoplasm
-Septal deviation
-Vascular malformation

Systemic
-Hemophilia
-Leukemia
-Liver Disease
-Platelet dysfunction
-Thrombocytopenic
-OSA/CPAP
-COPD/Home O2

Environmental
-Humidity
-Allergens
-Home O2