11 Tips to Improve Epistaxis Management in the Emergency Department

epistaxis 11 tips

Managing epistaxis is often challenging, time-consuming, and takes practice. Even under the best circumstances, epistaxis often results in return visits for rebleeding and poor outcomes. Rarely should you do “nothing” for adults who present to the ED with or following epistaxis. If it produced enough blood to seek care (even without hemodynamic compromise), epistaxis frequently recurs even if currently resolved. This is a less true in pediatric patients. A careful and comprehensive evaluation is essential in both populations, whether epistaxis is ongoing.

The following 11 pearls with a bonus tip should help you avoid common pitfalls, improve outcomes, and increase both patient and physician satisfaction:

  1. Wear proper protection during the procedure, including a face shield and gown. Nasal manipulation often causes patients to cough or sneeze, resulting in blood spray.
  2. Prepare your equipment in advance. Work with your nurses or techs to develop a policy where it is placed at the bedside when the patient is roomed. A bright, focused light is essential, ideally as a headlamp so both hands are free. This way, no assistant is needed. Cordless headlamps are easier to use but should be charged after each use.
  3. Although an elevated blood pressure or hypertension can worsen epistaxis, acute treatment is generally not required. Help your patient relax by establishing a calm presence, demonstrating confidence, and explaining your approach in advance. Done well, these actions are often sufficient to reduce their blood pressure.
  4. Have your patient slowly but firmly blow their nose to remove any clots that have formed, which not only will reduce or prevent medications from absorbing but will also interfere with visualization. After this, have your patient hold firm pressure with a clip or clamp for at least 15 minutes while you gather your supplies. If available, spray a vasoconstrictor such as oxymetazoline into the affected nostril(s) prior to holding firm pressure.
  5. Tight packing of your selected medications and your preferred method of their administration (e.g., cotton balls, pledgets, swabs) is crucial, as the vasoconstrictor/anesthetic won’t be well absorbed without direct contact and pressure. Tight packing also helps tamponade any bleeding. It may be necessary to pack both nasal cavities to achieve adequate tamponade because the septum is mobile.
  6. Avoid touching the nasal septum when using the nasal speculum. This is likely the area of bleeding and can be sensitive. Carefully insert the tip along the inner edge of the ala, open the speculum, then pull out with gentle traction to provide optimal visualization with your high-intensity light.
  7. If using silver nitrate to cauterize a friable area or visible vessel, ensure the field is dry and the site is anesthetized. Chemical burns are painful, and this area is sensitive. Using light pressure with a gentle rolling motion, cauterize an area slightly wider than the area of bleeding, limiting the number of repeat cautery attempts.
  8. If using commercial nasal packing that is too large (they come in several sizes, although some EDs stock only the largest sizes), shorten and trim the tip at an angle. Apply a topical antibiotic ointment to the nasal tampon to aid with insertion; this serves both as an antibiotic and lubricant. In some situations, using a hemostatic agent with the nasal tampon or in the nasal cavity may prove helpful. Follow the contour and direction of the nasal passage to ease insertion and minimize pain. Some patients poorly tolerate the placement of nasal packing and/or the packing itself.
  9. Add 1-3 ccs of water or saline using a syringe (no needle) to wet the packing following insertion. This allows the packing to expand and soften. Be prepared for a small amount of leaking, coughing, or spitting. If using an inflatable device for packing, be prepared to inflate the balloon to the optimal size with air or appropriate fluid (depending on the device).
  10. Do not immediately discharge a patient after successful epistaxis management. Observe your patient for a post-procedure recheck to ensure the bleeding remains well-controlled, your patient is tolerating the packing or balloon, and the vital signs are stable. This can be 15–30 minutes (or longer) depending on the amount of blood loss, the findings, the procedure, and your patient’s comorbidities.
  11. Know how and when to call for help. Call for help early in situations such as hemodynamic compromise due to blood loss, hypoxia or acute cardiopulmonary distress, post-surgical epistaxis, bleeding tumors (especially those that have been irradiated), patients with underlying bleeding disorders, an inability to control the bleeding, or other circumstances that make poor outcomes more likely.

Charting Bonus Tips: You can complete your patient’s discharge paperwork while waiting for the pre-procedure topical anesthetic/vasoconstrictor to take effect. During the post-procedure observation period, complete your chart and document your findings, the procedure, whether the patient tolerated the procedure, and any complications while observing your patient and awaiting the final set of vital signs before discharge.

Additional recommended reading

  • Gottlieb M, Long B. Managing Epistaxis. Ann Emerg Med. 2023;81(2):234-240. doi:10.1016/j.annemergmed.2022.07.002. PMID 36117013

Updated March 23, 2023

By |2023-03-23T23:41:34-07:00Mar 3, 2023|ENT|

Trick of the Trade: Managing Epistaxis with Merocel Nasal Packing and an Angiocatheter


There are many ways to manage epistaxis. Once nasal clamping and cauterization fail, the next step is to consider using tranexamic acid (TXA) and performing nasal packing. Inflatable packing devices such as a Rhinorocket are painful to insert and do not conform well to the shape of the naris. The expandable Merocel nasal packing, a compressed, dehydrated sponge, provides a softer, alternative option, although the insertion process can be painful given its initial rigid, edged structure. We propose 2 strategic tricks to optimize your nasal packing technique using the Merocel sponge.

Trick of the Trade: Strategic expansion of the Merocel sponge

The common approach for Merocel packing involves inserting the unexpanded sponge into the nose, tilting the patient’s head back, and dripping in TXA solution to expand the sponge to tamponade the bleeding.

Trick #1: Wet the tip of the Merocel’s sharp edge to allow for a softer cushion to slide the packing more comfortably and deeper into the naris.

Trick #2: Use an angiocatheter to deliver the TXA solution directly onto the mid-portion of the packing. Commonly, the TXA solution is dripped onto the outer end, which may cause an uneven and inadequate expansion at the site where the bleeding may be occurring. Because blood also can react with the packing, it is likely the blood will expand the packing before TXA reaches the center by osmosis. Another benefit of Merocel expansion starting at the center is that it will help anchor the sponge in place. In contrast, TXA administration at the outer tip first may pull the sponge out of the naris a few millimeters.

Equipment

  • 20g or 22g angiocatheter (closed IV catheter system)
  • Tranexamic acid solution
  • A syringe
  • Merocel nasal dressing

Technique

merocel sponge nasal packing trick setup

1. Insert the angiocatheter needle into the Merocel packing about ⅓ the distance from the external end of the packing. Remove the needle, leaving the plastic angiocatheter in place.

merocel tip moisten txa trick

2. Soak the insertion tip of the nasal packing with a drop of TXA to soften it. Or apply a light coat of an antibiotic ointment or petroleum jelly to the insertion tip for lubrication. This will make it easier to advance the packing and also less painful for patients. Advance the Merocel into the affected naris just as you would a nasogastric tube. Some additional tips are in the ALiEM article about nasogastric and nasopharyngeal tube insertion.

3. Once the nasal packing is fully inserted, expand the sponge by administering TXA via the attached angiocatheter. The mid-portion of the sponge should expand first, thus preventing outward slippage of packing. Also TXA more quickly reaches the area of bleeding rather than from a more gradual osmotic effect when dripped in from the external tip.

SAEM Clinical Image Series: A Rapidly Spreading Rash

spreading rash

A 40-year-old male with a past medical history of HIV presented for evaluation of a non-pruritic rash. Six days ago, he suddenly felt a stinging sensation at the back of his head and neck similar to a bug bite. He then noticed bumps were starting to form and developed a shock-like pain in the area. Three days ago, the rash spread from the back of his head towards his chest. Yesterday, the rash spread further and now extends medially and upwards covering most of his left neck and ear. The pain continued to worsen, at which point the patient shaved the left side of his head in an attempt to help the rash. Today, the pain became unbearable, which prompted his visit to the emergency department for further evaluation and management.

Head: Normocephalic, atraumatic; left side of patient’s head is shaved.

Eye: Pupils equal, round, reactive to light; extraocular movements intact; no corneal ulcers or dendritic lesions with fluorescein staining.

Visual acuities: Right 20/25, left 20/25, baseline 20/25

Ear, nose, throat: Mucous membranes are dry; oral thrush and tonsillar erythema appreciated; localized erythema, crusting and blistering rash of varying sizes and ages along with the outer ear including the tragus, antihelix, and antitragus; helix mildly swollen. On otoscopy, the tympanic membranes appear pearly grey, shiny, translucent with no bulging, and without cerumen impaction.

Neck: Full range of motion appreciated but both horizontal and vertical movement is slow secondary to pain; no lymphadenopathy.

Neurological: Awake, alert, and oriented to date, place, and person; moves all extremities; cranial nerves II through XII grossly intact; strength 5/5 in all extremities; gait steady; no ataxia, dysmetria, or dysarthria.

Skin: Erythematous, localized, crusted, blistering vesicular rash of various sizes and ages appreciated along the left V3 distribution, C3 to T3 dermatomes anteriorly, and C2 to C6 dermatomes posteriorly.

HIV-1 antibody: positive

CD4 helper t-cells: 48 (L)

HIV-1 RNA PCR: 36,490

The lesions can be characterized as vesicles in various stages of healing. Some lesions are crusted, others are bullous, and a few are pustular. The C2-C6 dermatomes are affected posteriorly, and the C2-T3 dermatomes are involved anteriorly.

The diagnosis is Disseminated Herpes Zoster. The rash in reactivation varicella zoster virus (VZV) is preceded by tingling, itching, or pain, and begins as maculopapular then progresses to vesicles, pustules, and bullae. The rash typically involves a single dermatome and does not cross the midline. Rash present in multiple dermatomes (>3) or a rash that crosses the midline signifies disseminated disease. Hutchinson’s sign is a lesion on the lateral dorsum and tip of the nose indicating the involvement of the nasociliary branch of the ophthalmic division of the trigeminal nerve. The nasociliary branch innervates the eye, thus these lesions are highly suspicious for herpes zoster ophthalmicus. Herpes zoster ophthalmicus on fluorescein examination appears as pseuododendritic lesions with no terminal bulbs (not to be confused with herpes simplex virus (HSV) keratitis, which has dendritic lesions with terminal bulbs). Vesicles in the auditory canal (herpes zoster oticus) may be a part of Ramsay Hunt syndrome with ear pain and paralysis of the facial nerve.

The patient is immunocompromised and requires hospitalization for intravenous (IV) antiviral therapy and pain management. VZV primary infection results in viremia, diffuse rash, and seeding of sensory ganglia where the virus establishes latency. Herpes zoster is the result of viral reactivation with spread along the sensory nerve in that dermatome. Antiviral therapy aids in the resolution of lesions, reduces the formation of new lesions, reduces viral shedding, and decreases the severity of acute pain, but does not affect the development of post-herpetic neuralgia.

Immunocompetent patients may receive Valacyclovir 1 g PO q8hrs (preferred) or Acyclovir 800 mg PO 5x/day x 7d if the onset of rash is <3 days or >3 days with the appearance of new lesions.

Immunocompromised, transplant, and cancer patients are all at high risk for dissemination, chronic skin lesions, acyclovir-resistant VZV, and multi-organ involvement. Immunocompromised patients and patients with disseminated zoster require aggressive multimodal treatment, admission to the hospital, and IV antiviral therapy regardless of the time of onset of rash. Recommended therapy is Acyclovir 10 mg/kg IV q8h or Foscarnet 40 mg/kg IV q8h for acyclovir-resistant VZV. All patients require adequate analgesia, typically with non-steroidal anti-inflammatory drugs, opioids, Gabapentin, Nortriptyline, and Lidocaine patches on intact skin.

Take-Home Points

  • Disseminated herpes zoster is defined as reactivation of VZV in three or more dermatomes. It requires admission, IV antiviral therapy, and pain control.
  • If VZV reactivation involves the face, one must evaluate for herpes zoster ophthalmicus and oticus.
  • Perform a thorough neuro exam including evaluation of cranial nerves V, VII, and VIII.
  • VZV requires airborne precautions.
  1. Cohen JI. Clinical practice: Herpes zoster. N Engl J Med. 2013 Jul 18;369(3):255-63. doi: 10.1056/NEJMcp1302674. PMID: 23863052; PMCID: PMC4789101.

 

 

 

SAEM Clinical Image Series: Edema Got Your Tongue?

angioedema

A 57-year-old male presented to the emergency department with a swollen mouth for three hours. He reported never having experienced this before and denied starting any new medications. The patient endorsed a feeling that his mouth was swollen and had difficulty swallowing. The edema had been increasing in size since its onset. He had been drooling for the past hour and endorsed mild pain around the area. He denied any shortness of breath, rash, nausea, vomiting, or other areas of edema. His past medical history included hypertension, diabetes, and allergies, with no known drug allergies. His family history was unknown. His medications included Metformin and Lisinopril.

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SAEM Clinical Image Series: Left Ear Mass

ear mass

A 25-year-old male who was previously healthy presents to the emergency department with a painful left posterior ear mass. The mass began as a “pimple” and has been increasing in size for the last 6 months. He has an associated headache, dizziness, and malaise. He denies fever, trauma, drainage, known insect bite, dysphagia, dyspnea, trismus, and hearing loss. He emigrated to the United States from Honduras 8 months ago. He was seen in the emergency department 4 months prior for a similar complaint, which was diagnosed as lymphadenopathy by point-of-care ultrasound.

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SAEM Clinical Image Series: The Hemorrhaging Bifurcated Tongue

bifurcated tongue

A 26-year-old male with no past medical history presented to the emergency department for tongue bleeding for one day. Five days prior he had an elective cosmetic tongue bifurcation completed out-of-state. About two hours prior to arrival, he had been using a swish-and-spit saltwater rinse when he felt a suture break. Ever since he has had copious bleeding, reportedly filling his sink at home with blood. Additionally, he had about 250 milliliters of blood, including large clots, in a container in the emergency department. He denied using any blood thinners. There was no syncope, dizziness, chest pain, nausea, vomiting, shortness of breath, pain of the tongue, or numbness of the tongue. He had some difficulty speaking but said it was due to needing to retrain his bifurcated tongue.

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SAEM Clinical Image Series: Oral Trauma and Mass

oral mass

A 38-year-old African American male without a significant past medical history presented with an oral mass. He was struck on the mouth by a wrench handle about two prior. Since then he has had a growing mass originating from the gum of his left front upper teeth. He is no longer able to eat solid foods and has to use a straw for all oral intake. The patient denies fevers, chest pain, shortness of breath, and weight loss.

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By |2020-12-11T15:18:37-08:00Dec 14, 2020|Academic, ENT, SAEM Clinical Images|
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