Epistaxis
Epistaxis
Patients with epistaxis that cannot be sufficiently controlled to discharge home from ED.
Hemodynamically Stable
Volume of bleeding does not pose risk to airway.
Epistaxis management (packing) completed in main ED.
DOACs and Anti-Platelets are OK IF they can be safely held
Platelets > 50k
Significant (greater than 3) drop in Hb.
Ongoing visible bleeding despite bilateral anterior packing
Supratherapeutic on Warfarin Anticoagulation. e.g. INR > 3.5 (DOACs, Antiplatelets OK)
Mechanical Valve on warfarin or PCI in last 3 months requiring antiplatelets without interruption.
High suspicion for posterior bleeding (should discuss with ENT while in main ED)
H/H Q8hr
Continuous Pulse Oximetry
ENT consultation for any recurrent or refractory bleeding
Hold anticoagulation and antiplatelet agents if reasonable
AC for A-fib prophylaxis or chronic remote PE/DVT is usually fine to hold until followup
Anti-platelets for primary or secondary prevention of CAD/Stroke can usually be held until followup.
Do not hold AC in a patient with a recent thromboembolic event
Do not hold Anti-platelets in patients with a vascular stent within the last year.
Antibiotics
Despite what we were all taught in residency, systemic antibiotics are not helpful in Nasal Packing (Hu et al 2021)
Nerve Blocks for Bleeding Control
Big surprise, there is a nerve block (pterygopalatine fossa injection) that can actually cause vasoconstriction of the sphenopalatine artery and reduce epistaxis. It will also result in increased patient comfort with packing. If you think your patient needs this, talk to Zeccola (Shanoy et al 2017)
Disposition
No ongoing evidence of bleeding
Followup with PCP, ENT or ED for packing removal in 48 hours
Hemodynamically stable
Ongoing bleeding either from nares or back of throat despite above interventions for 18 hours
Unstable Vital Signs
Ongoing drop in H/H
Per ENT Consultation
Learning Links:
Hu L, Gordon SA, Swaminathan A, Wu T, Lebowitz R, Lieberman S. Utilization of Prophylactic Antibiotics After Nasal Packing for Epistaxis. J Emerg Med. 2021 Feb;60(2):144-149. doi: 10.1016/j.jemermed.2020.10.011. Epub 2020 Nov 7. PMID: 33168390.
Shenoy VS, Prakash N, Kamath PM, Rao RA, Deviprasad D, Prasad V, Kamboj V, Borra LK. Is Pterygopalatine Fossa Injection with Adrenaline an Effective Technique for Better Surgical Field in Fess? Indian J Otolaryngol Head Neck Surg. 2017 Dec;69(4):464-473. doi: 10.1007/s12070-017-1225-z. Epub 2017 Oct 10. PMID: 29238675; PMCID: PMC5714914.
Biggs TC, Nightingale K, Patel NN, Salib RJ. Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Ann R Coll Surg Engl. 2013 Jan;95(1):40-2. doi: 10.1308/003588413X13511609954734. PMID: 23317726; PMCID: PMC3964636.