Epistaxis Brief Review - Michael Plewa, MD

We covered epistaxis in our last flipped classroom session. Here is a quick summary of the management of nose bleeds, courtesy of Dr. Plewa!

History: estimated blood loss, history of anticoagulant, thrombocytopenia, anterior or posterior
Labs: Consider CBC (platelets), PT, PTT
Position patient upright, gown/towel, clamp/squeeze, provide emesis basin/bag, tissues/gauze
Don mask/goggles, gown, gloves, headlight
Remove clot by gentle nose blow, suction or alligator forceps
Visualize anterior plexus for bleeder, gently swab with cotton-tipped applicator to be certain
Topical anesthesia, soak pledgets in solution:

Afrin (oxymetazoline) or Neo-synephrine (phenylephrine) with Lidocaine 1-4%

XAP/LET (lidocaine 4%, epinephrine 0.1%, tetracaine 0.4%)

Sliver nitrate cautery (few seconds touch, roll, lift), swab with cotton-tipped applicator

TXA 500 mg in 5 ml, atomize 1-2.5 ml, or soak pledget/packing
Thrombin-JMI (5,000 U powder in 5 ml saline) atomize 1-2.5 ml or soak pledget/packing
Insert Merocel sponge (coated with Bacitracin) along floor of nose, then inflate with saline
Insert Rapid Rhino (soaked for 30 sec in sterile water), inflate with air 10-20 ml
Options: Surgicel or Oxycel (oxidized cellulose), Gelfoam, salt pork, FloSeal (biodegradable, gelatin-thrombin)
Persistent anterior: TXA or Thrombin, bilateral or longer packing, trade sponge for Rapid Rhino (more air)
Posterior:

7.5/10 cm Rapid Rhino or Merocel (after TXA or Thrombin), contralateral pack or sponge if persistent

Atomize TXA or Thrombin, IV sedation or analgesia:

Observe for 1 hour, stress-test: ambulate, bend over, move, to observe for re-bleed
If posterior pack placed: Admit, supplemental oxygen, monitor, analgesics, antibiotics, ENT consultation
If anterior pack placed:

Antibiotics for (Bactrim (MRSA), Keflex, Augmentin) for sinusitis, toxic shock syndrome

Analgesics

Follow-up in 3 days to ENT

Avoid picking, blowing; educate regarding 5 min pressure or nose-clamp

Keep moist with saline spray, bacitracin or Vaseline

OTC: NosebleedQR

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