Emergency medicine manual Nasal Emergencies and Sinusitis Epistaxis Epistaxis is classified as anterior or posterior.

Posterior epistaxis is suggested if an anterior source is not visualized, if bleeding occurs from both nares, or if blood is seen draining into the posterior pharynx after anterior sources have been controlled. Anterior and posterior epistaxes requires an initial evaluation to identify and control the source. 1. A quick history should determine the duration and severity of the hemorrhage and the contributing factors (trauma, anticoagulant use, infection, bleeding diathesis, etc). 2. The patient should blow the nose to dislodge any clots. 3. A quick inspection is made to identify obvious anterior sources. A Frazier suction catheter will help keep the passage clear. 4. Cotton swabs or pledgets moistened with a topical anesthetic or vasoconstrictor are inserted into the nasal cavity with bayonet forceps. Four percent lidocaine provides excellent results when mixed with 1:1000 epinephrine, 1% phenylephrine, or 0.05% oxymetazoline. 5. Direct external pressure is then applied for 15 minutes. Active bleeding into the pharynx despite direct pressure suggests inadequate pressure, drainage from a clot in the posterior nasal cavity, or true posterior epistaxis. 6. If this approach fails, it should be repeated 1 or 2 more times. If still unsuccessful and the source of bleeding is anterior, an anterior pack may be inserted or local cautery may be attempted if the source of bleeding is easily identified and is a discrete area of bleeding. 7. Chemical cautery with silver nitrate is the standard of care for emergency department (ED) cautery of anterior epistaxis. After hemostasis is achieved, the mucosa is cauterized by firmly rolling the tip of a silver nitrate applicator over the area until it turns silvery-black. A small surrounding area also should be cauterized to control local arterioles. Overzealous use of cautery is discouraged because it may cause septal perforation and unintended local tissue necrosis. 8. Anterior nasal packing may be performed with gauze or commercial devices. One popular device is the Merocel nasal sponge (Merocel Corp, Mystic, CT), a compact, dehydrated sponge available in several lengths to control anterior and posterior epistaxes. The sponge is rapidly inserted along the floor of the nasal cavity and then expands upon contact with blood or secretions. A film of antibiotic ointment applied to the sponge will ease insertion and reduce chances of infection. After insertion, expansion is hastened by rehydrating the sponge with sterile water from a catheter-tipped syringe after the sponge has been inserted. A mixture of

lidocaine and a topical vasoconstrictor also may be used to hydrate the sponge and provide topical anesthesia and vasoconstriction. The longer sponges used to control posterior hemorrhages have been associated with some morbidity and should be used only when indicated; they are not indicated for the control of isolated anterior epistaxis. A variety of commercially available nasal tampons can be used, some with inflatable balloons that can control anterior and/or posterior hemorrhage. All nasal packs are removed in 2 to 3 days by an ENT physician. 9. If packing or local cautery fails to control anterior bleeding, ENT consultation is necessary. 10. Posterior epistaxis may be treated with a dehydrated posterior sponge pack, as outlined above, or a commercial balloon tamponade device. The balloon devices use independently inflatable anterior and posterior balloons to quickly control refractory epistaxis at these sites; the instructions for insertion are included in the balloon kit. To protect against potentially serious complications, all patients with posterior packs require ENT consultation for possible hospital admission. Posterior packs are removed in 2 to 3 days after placement. 11. Complications of nasal packing include dislodgment of the pack, recurrent bleeding, sinusitis, and toxic shock syndrome. All patients with nasal packs should be started on antibiotic prophylaxis with cephalexin 250500 mg PO q6h or amoxicillin/clavulanate 250/125 mg PO q8h. Penicillin-allergic patients may be given clindamycin or trimethoprim/sulfamethoxazole.