Posterior (?) Epistaxis Packing

[highdesert]

I'm curious what some of the more experienced EPs feel about this one...

As a PGY-3, I've packed a fair share of noses -- mostly anterior packs. I've done a handful of true posterior packs, generally using a foley. When I do a posterior pack, I admit all of those patients. The other day I used a Bausch & Lomb Epistaxis Catheter for a bleed that resisted anterior packing. I inflated the posterior balloon with about 6cc (out of 10cc) and the anterior with just under 30 cc. I watched the guy for about 1 hour to make sure he could tolerate the pack, and sent him home with Keflex and Vicodin.

He returned 2 days later and another (attending) ED physician deflated the posterior balloon without rebleeding. As soon as he deflated the anterior portion, the patient rebled. ENT was consulted and threw a fit that the patient had been sent home with the posterior balloon inflated. The ED doc that consulted ENT told them that he routinely sends people home with the posterior balloon inflated, unless they are unable to tolerate it or have underlying comorbid illnesses. The ENT attending got involved and remarked that he 'hates' the catheters and wants them removed from the ED. Obviously, this has generated a fair amount of strong emotion on both sides of the divide.

My straw poll of 8 attendings in my program revealed that 7/8 do not consider the epistaxis catheter a true posterior pack. Roberts and Hedges states that a dual balloon catheter may be used for outpatient management, even with the posterior balloon inflated. My quick search of the literature (including ENT literature) doesn't clearly delineate the issue one way or the other.

How many of you admit every patient with a dual balloon catheter with an even partially inflated posterior balloon? Do you consider the use of a dual balloon catheter a true posterior pack?

Curious.

HighDesert

---

Members don't see this ad.

 

[Seaglass]

I thought I had read somewhere that there is a higher incidence of airway compromise from posterior packs and that is why we don't send them home. I agree that it wasn't really a posterior pack and therefore can be sent home but AFAIK we admit all true posterior packs.

 

[Sessamoid]

I've sent home patients with the balloon catheters before, but generally I phone consult ENT before they are discharged. There's a much higher probabilty that the ENT consulted will be very happy with that management if the patient is uninsured. (On a side note, please remember the prophylactic antibiotics if you send them home packed. Sinusitis from nasal packings is pretty ugly.)

When consultants like that throw a fit, I either just let them vent or ask them if they'd like to be consulted on every nosebleed (fracture or whatever) that walks in the door. Historically, I've only known a couple cases where they said yes. One or two weeks of no sleep at night and they pretty quickly recant. I'd handle this the same way. If you remove the tool of the posterior balloon catheters from our toolbox, then all those previously discharged patients are going to have ENT called in for packing and admission to their service.

 

[docB]

I consider the dual balloon to be about as close to a posterior pack as I want to get. I don't send those pts home though because of the possibility of airway problems. I don't have ENT on call at any of my hospitals so if I do a dual balloon I usually transfer the patient.

 

[southerndoc]

Not only is sinusitis ugly, but toxic shock syndrome from packings can be ugly as well.

If a specialist has an opinion about how a patient is managed, then I usually respect their opinion. Afterall, they are the specialist in their field. Having said that, we admit patients who receive posterior packing. We do it the old fashioned way though.

 

[Scrubbs]

My straw poll of 8 attendings in my program revealed that 7/8 do not consider the epistaxis catheter a true posterior pack. Roberts and Hedges states that a dual balloon catheter may be used for outpatient management, even with the posterior balloon inflated. My quick search of the literature (including ENT literature) doesn't clearly delineate the issue one way or the other.

We use the dual balloon catheters for all posterior bleeds - and admit all of them. Roberts and Hedges may say you can use them for outpatient management, but I can tell you from personal experience that Roberts' would admit the patient.

 

[EMResident]

We use the dual balloon catheters for all posterior bleeds - and admit all of them. Roberts and Hedges may say you can use them for outpatient management, but I can tell you from personal experience that Roberts' would admit the patient.

I always admit posterior bleeds/posterior packs, specifically for airway monitoring. I've never had a patient not require significant analgesia to tolerate the pack, and narcotics + balloons in and around the oropharynx = nervous about going home.

The thing that most troubles me is after the balloon is inflated and the patient's eye "bleeds" as the pressure forces blood out of the nasolacrimal duct! The patient was crying that she couldn't see and I had looked away, only to look back and see blood streaming down her cheek!

 

[jazz]

Roberts and Hedges states that a dual balloon catheter may be used for outpatient management, even with the posterior balloon inflated.

this is straight from Roberts and Hedges (4th edition)

Complications associated with posterior packing include infection, dysphagia, eustachian tube dysfunction, tissue necrosis, and dislodgment. Other serious complications associated with posterior packing are hypoxia, hypercarbia, aspiration, hypertension, bradycardia, arrhythmias, myocardial infarction, and death. [51] Therefore, most patients, with a posterior pack, especially the elderly and those with pulmonary and cardiovascular diseases, should be admitted to the hospital for sedation and monitoring. This recommendation was common for formal posterior packs, but the ease and safety of the balloon devices now allow select patients to be treated as outpatients despite the presence of posterior packing.

Infection risk with posterior packing includes toxic shock syndrome, nasopharyngitis, and sinusitis. The packing blocks the sinus ostia, preventing proper drainage of the sinuses. In addition to coating the packing with antibiotic ointment, broad-spectrum antibiotics should be administered. Dysphagia due to the packing can lead to poor oral intake, and IV fluid hydration may be required.

A significant decrease in PaO2 (7.5 to 11 torr) and increase in PaCO2 (7 to 13 torr) is seen in patients with nasal packing who are treated with sedation.[53] A posterior pack will cause vagal stimulation, resulting in varying degrees of bradycardia and bronchoconstriction. This physiologic adaptation is even more worrisome in patients with underlying lung or heart disease. With the risk of hypercarbia and hypoxia, patients with lung disease with posterior nasal packs should be closely monitored in an intensive care setting.

Tissue necrosis of the nasal ala, nasal mucosa, and soft palate has been described secondary to improper placement or padding. Protecting the skin with gauze placed under the device will reduce skin maceration. The risk of necrosis increases with the duration of the packing, so all packing should be removed in 3 to 5 days. Bleeding from the nasolacrimal duct is a common benign problem with nasal packing

If the posterior pack becomes dislodged, it will fall into the oropharynx with the risk of asphyxiation, vomiting, and aspiration. The patient and nursing personnel need to be familiar with the technique for removing the pack. To accomplish this, cut the anterior sutures that exit the naris from the gauze roll if they have not already broken. Grasp the sutures exiting the mouth and guide the packing out of the nasopharynx. It may be necessary to manually extract the packing with forceps or digits.



****
To me, the risk of bad complications is too high to send anyone home with a posterior pack. Roberts and Hedges has one brief line about being ok to send home posterior packs in select patients but has paragraphs on possible poor outcomes. In the hospitals I have worked in, posterior packs get admitted to ICU/step down settings.

 

[drpcb]

My practice is always admit anything remotely resembling a posterior nose packing to a monitored setting because of the risks of respiratory issues. That being said, I haven't yet sent home a posterior packing from a community hospital, these have been in residency. This would be my practice:

Insured; posterior packed: Easy admission.
Uninsured; posterior packed: If the specialist balks, transfer for higher level of care to get admitted.

I see no reason to risk it with this relatively rare condition.