any epistaxis nightmares? how'd u manage it?

[Painter1]

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had my first profuse epistaxis. all of my previous cases they either had stopped by the time they got there or it was a managable slow drip. i'd revert straight to rhino rocket.

this time, it was 60ish female, no coumadin but comes in with epistaxis that gained momentum then became a full force torrent.

couldn't thread rhino rocket, still not sure why i had a hard time putting it through. finally placed the 9.5cm anterior/posterior rhinorocket but the patient is spewing blood through her mouth now claming that: "i'm dying!". it didn't help she was a fibromyalgia patient who was fullblown hysterical.

called ENT stat but surprisingly, they weren't calling back.

what would be ure guys next move?

 

[future_dr_house]

Was she hypertensive? If diastolic is > 100 rhino rockets probably won't work or at least they haven't for me.

Otherwise, maybe there's a systemic cause or underlying nasopharyngeal cancer or AVM.

 

[txterp98]

I once had a pretty dicey situation where I was packing as best as I could while hanging O-neg blood simultaneously.

I was able to coordinate sending the patient stat to IR for a selective embolization of the bleeding vessel.

Trust me...it's not lost on me how lucky I am to have backup like this where I work.

Just something to keep in the back of your mind if this is possible where you are.

 

[Hamhock]

Was she hypertensive? If diastolic is > 100 rhino rockets probably won't work or at least they haven't for me. \

Wrong. (regarding BP)

If you are an EM-tained doc and that scared, don't F around.

ETT.

Pack.

Posteriorly and anteriorly.

Identify any obviously lessions.

Be agressive about posteriror sources.

Correct coagulopathy.

Address posterior bleeds.

Contact IR (esp posterior bleeds) and ENT. IR is your friend in this situation.

Hope for the best.

HH

just don't rhino and pray

 

[Interpolfanclub]

Agree. I've helped another EM doc intubate a nose bleed because we were unable to control it with the above means. I've seen several people almost croak from nose bleeds. BP control, products, 7.5cm rockets, intubation, ENT.

 

[Hamhock]

Agree. I've helped another EM doc intubate a nose bleed because we were unable to control it with the above means. I've seen several people almost croak from nose bleeds. BP control, products, 7.5cm rockets, intubation, ENT.

and forgert BP control...when the patient is dying, it is time to be aggressive...more like a surgeon, less like a flea

HH

 

[Tiger26]

and forgert BP control...when the patient is dying, it is time to be aggressive...more like a surgeon, less like a flea

HH

Agree--also, the HTN is largely secondary to anxiety. It's not unreasonable to throw in a little benzo here and there to get 'em more cooperative.

My approach:

-blow out the clot
-cotton balls soaked in lido w/epi stuffed in or viscous lido with phenyleprine mixed
-cauterize if possible
-murocel with surgicel wrapped around it
-if not working, posterior pack
-if not working, IR and if necessary intubation

 

[UnderwaterDoc]

I have seen a foley used to control nasty posterior bleeds, pass the catheter, inflate the balloon, apply outward traction, it stopped the bleed in this particular case long enough for us to call ENT and send the pt upstairs.

It did seem McGuyver-ish when we did it, so your mileage may vary.

 

[future_dr_house]

Wrong. (regarding BP)

If you are an EM-tained doc and that scared, don't F around.

ETT.

Pack.

Posteriorly and anteriorly.

Identify any obviously lessions.

Be agressive about posteriror sources.

Correct coagulopathy.

Address posterior bleeds.

Contact IR (esp posterior bleeds) and ENT. IR is your friend in this situation.

Hope for the best.

HH

just don't rhino and pray

Agreed. Trial by fire didn't work for me and I wasn't trying to advocate that approach. Thanks for your input.