Massive epistaxis is considered a medical emergency that requires immediate attention. Symptoms of massive epistaxis include sudden and heavy bleeding from the nose, difficulty breathing, dizziness, and a rapid heartbeat. If left untreated, it can lead to significant blood loss, shock, airway obstruction, and even death. We report a case of a 50-year-old man with end stage renal disease with massive nasal bleeding from the left nostril, shortness of breath, and confusion.

Initial Management

After a rapid assessment, we inserted an anterior nasal pack, soaked in epinephrine, TXA, and an antibiotic-based lubricant. However, the bleeding continued from his nares and posterior oropharynx. We thus removed the anterior packing and instead inserted a Foley catheter into the posterior nasal space and inflated the balloon. Unfortunately, the bleeding still continued. Because he presumably had uremia-induced thrombasthenia (weak platelets), he received blood transfusions and IV TXA. And still — he continued bleeding heavily.

Trick of the Trade: Dual Catheter Technique

To provide optimal surface area coverage and tamponade effect of the posterior vessels, concurrent anterior packing is usually needed [1]. You can use commercial devices that have a dual balloon setup, but we did not have that available.

Illustration by Dr. Abdelhameed with patient-consented photo of dual balloon technique

Technique

1. Insert the a 14-French Foley catheter into the nares with the patient’s mouth open (balloon 1). Stop when you see the tip of the catheter dangling in the posterior oropharynx.
2. Inflate the balloon partially with 15-20 cc of air.
3. Gently pull the catheter anteriorly until you feel resistance such that the balloon is snuggly positioned.
4. If the bleeding still continues, insert a second Foley catheter until you meet resistance (balloon 2). Inflate this second balloon with 15 cc of air.

For our case, this dual catheter compression technique succeeded in halting the bleed.

Interested in Other Tricks of the Trade?

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Reference

1. Goralnick E. Posterior Epistaxis Nasal Packing. Medscape. Published Dec 9, 2020

A young boy is brought to the pediatric emergency screaming at the top of his lungs by his parents. His penile skin is trapped in the zipper of his jeans. On a busy shift, you want a simple way to handle zipper injuries that minimizes pain, doesn’t require resource-intensive procedural sedation, and is quick.

Background

The 4 most common types of zippers are nylon coil zip, plastic mold zip, metal zip, and invisible zip. Most of the techniques describing solutions on zipper entrapment in the medical literature are derived from case reports and case series. All revolve around understanding zipper anatomy and obtaining adequate exposure to assess how the skin is entrapped. The penile skin often is entrapped either in the sliding mechanism (also known as the endplate) or between the teeth of the zipper.

Figure 1. Anatomy of a zipper

Penile Entrapment Injury Management Techniques in Literature

Reported techniques for releasing zippers include [1, 2]:

• Cut the sliding mechanism (aka the endplate) using metal cutters.
• Use a flat screwdriver placed underneath the sliding mechanism and rotate it.
• Use mineral oil for lubrication.
• Use lateral compression technique to relieve the tension on the trapped skin.
• Cut the zipper and pull the teeth apart.

All these techniques are associated with variable rates of success. Some of these techniques such as using metal cutters might lead to iatrogenic injuries.

The problem is that the child’s penile skin is entrapped within a metal zipper, where many recommended methods for zipper entrapment removal won’t work.

Trick of the Trade: Removing Metal Zippers

Materials Needed

• Lidocaine gel
• Blade or scissors

Technique

1. The zipper should be separated from the pants as much as possible to minimize painful stretching or pulling of the penile skin.
2. Apply lidocaine gel on the area of entrapment for 2-3 minutes.
3. Identify the exposed teeth closest to slider and cut off the zipper at that level (blue dots) while avoiding penile skin (Figure 2).
4. Gently advance the zipper body forward, pulling either the tab or the body itself, to disengage it from the teeth. You may need to add more lidocaine gel or other lubrication to facilitate this sliding motion.
5. The remaining parts of the zipper can easily be disengaged from the skin (Figure 3).

Figure 2. Cutting off the zipper between the teeth (blue dots) and advancing the zipper body (yellow arrow)

Figure 3. Freed zipper body

Interested in Other Tricks of the Trade?

• Read the series
• Buy the print book!

References

1. Leslie SW, Sajjad H, Taylor RS. Penile Zipper and Ring Injuries. [Updated 2023 Mar 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
2. Tasian GE, Belfer RA. Genitourinary trauma. In: Fleisher and Ludwig’s Textbook of Pediatric Emergency Medicine, 7th ed, Shaw K, Bachur RG (Eds), Lippincott Williams & Wilkins, Philadelphia 2015.