NosEmergencies - Dr. M. Zeller

Epistaxis

• Epistaxis is classified as either anterior or posterior.
  • Anterior epistaxis usually originates in the vascular watershed area of the nasal septum known as Kiesselbach's plexus involving the ethmoidal artery, sphenopalatine artery, and facial artery.
  • Posterior epistaxis usually originates from the sphenopalatine artery but may also arise from the internal carotid artery.
• Diagnostic studies of coagulation panel, hemoglobin, and platelet count are not necessary in the typical healthy patient with epistaxis.
• 65% of cases achieve hemostasis with use of topical vasoconstrictive agent and 10 minutes of continues pressure of the septum.
• Maintain the patient in “sniffing position” during examination to obtain the best possible views of the anatomy.
• If anterior source is identified, then attempt cauterization.
• If patient remains symptomatic, pack the anterior naris.  Be sure to provide anxiolytics as this is incredibly uncomfortable for the patient.  Anterior packing of bilateral nares may be required in order to provide a counterforce to the lesion.
• There are few studies concerning the use of antibiotics in patients with nasal packing for TSS prophylaxis, but most specialists recommend initiating Augmentin.
• If patient continues to bleed, it is most likely a posterior bleed and will require posterior packing.  A Foley catheter (10-14 French) can be used for posterior packing in a pinch.
• Patients with posterior packing could theoretically undergo lethal bradydysrithmias and should be admitted to a monitored bed.

 Foreign Bodies

• Button batteries and paired disc magnets are especially harmful.
• Most nasal foreign bodies are radiolucent.
• Patients often present with unilateral mucopurulent drainage.
• Initial attempts at removal should involve positive pressure techniques.
  • Have the patient blow his or her nose while occluding the nostril opposite of the FB.
  • “Mothers Kiss” involves having the parent provide oral positive pressure to a pediatric patient while occluding the unaffected nostril.
  • You can provide 15 L/min of O2 via a soft rubber Christmas tree to the unaffected naris, if a pediatric patient refuses to open their mouth.
• If positive pressure fails, helpful tools for manual extraction include otoscope, nasal speculum, curette, forceps, suction, and/or Katz catheter.  A pediatric foley catheter (5 french) can be substituted for a Katz catheter.
• Remember to use sedation and application of local analgesic and vasoconstrictive agents prior to manual extraction.

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