Episode 11: Epistaxis in the Field

Listen here, or download on iTunes, Podcast Addicts, or Podcast Republic. 

 

Nasal Vascular Anatomy

All of us are guilty of oversimplifying the complicated. Conversely, there are a few of us that overcomplicate the simple. Some of you might be scratching your heads wondering why in God’s green earth we are doing an episode about epistaxis. Nosebleeds? Yup. We’re not above it, and neither should you be. This is a pretty common run, especially during the changing seasons, and there can be pretty dire consequences if it is mismanaged. Think about the populations that are already prone to dehydration. Geriatrics. Pediatrics. Smaller volume loss can have very detrimental consequences.

WHAT’S THE LOC OF YOUR PATIENT?

  • Is your airway patent?
  • Suctioning needed? Ventilatory support?
  • Is there bleeding going into the oropharynx?

UNDERLYING CAUSES OF EPISTAXIS

  • Medical:
    • Increased ICP
    • Compartmental hemorrhage
      • Dissecting aneurysm, etc
      • Wherever there is free flowing blood, it will look for an exit
  • Trauma:
    • Pretty self explanatory, but whenever the MOI is significant enough to cause facial trauma prepare for other life-threatening consequences
      • Yes… Nose picking counts as trauma
    • Neuro deficits?
    • Airway Compromise?
    • Spinal compromise?
  • Chemical:
    • Any type of inhalants can cause nasal membrane sensitivity
      • Cocaine, meth, etc
    • ETOH works as a blood thinner
      • We all know that drunks have a poor center of balance…
    • INR Levels
  • Environmental:
    • When the weather changes, nasal membranes dry out causing increased sensitivity

COMPLICATIONS

  • ETOH
  • Blood thinners
  • Hypertension

SPECIAL CONSIDERATIONS

  • Use caution with anterior pressure in trauma
    • 90% of epistaxis are anterior bleeds; typically slight pressure on the anterior bridge of the nose is enough to stop the bleeding
  • Is the patient on any β-blockers that inhibit initial signs of fluid depletion?

HEMORRHAGE CONTROL

  • Remember that any patients that are normotensive/hypertensive will present difficulty in controlling hemorrhage
  • Treat any type of severe epistaxis like you would any type of exsanguination
    • Permissive hypotension
    • Consider fluid boluses if hypotensive
    • Non-TBI: 80-90mmHg
  • TBI: 90-100mmHg
  • What happens when epistaxis doesn’t stop with pressure?
  • Anterior packing?
    • Caution in facial trauma; ironically worsens hemorrhage as well as creates increased facial trauma leading to increased ICP, airway compromise, etc;
    • Anterior packing can inhibit attempts to properly ventilate and oxygenate patients
  • New upcoming treatment; transdermal TXA in nasal packing
  • Steps to prevent insertion errors; prehospital packing typically discouraged; something to discuss with your medical director; anterior packing with tampon sponge
  • If fluids are indicated, consider blood products/TXA

EXPELLING THE MYTHS OF EPISTAXIS

  • Ice pack to back of neck to promote nasal vasoconstriction?
  • Epistaxis is not a sign/symptom of a hypertensive crisis; it’s an indirect symptom
    • Are there any other signs that could cause the HTN? Neuro deficit; cardiac symptoms?

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