The anterior balloon is then filled with up to mL of saline. The Epistat II has a posterior balloon and an anterior Merocel nasal tampon. Although quick and easy to place, the balloon packs may not always be successful as they tend to fill in areas of least resistance.
The packs also sometimes put severe pressure on the septum and can be quite painful. The association between hypertension and epistaxis is complicated. Hypertension does not cause epistaxis but may prolong it. Therapy focuses on control of the hemorrhage rather than reduction of the blood pressure.
Analgesia and mild sedation are preferable to antihypertensive therapy. For patients with severe or recurrent hemorrhage or underlying medical conditions, a complete blood count should be performed, as well as a type and screen.
In selected patients, such as those taking warfarin or with hepatic or renal dysfunction, coagulation studies are warranted. No matter the choice of treatment, the patient should be observed for at least 1 hour after control.
Encourage the patient to walk or perform other activities that he or she will need to resume when returning home. In the patient treated by cautery, Vaseline or a similar moisturizing agent should be applied liberally in the nose three times a day for days to promote healing of friable mucosa and superficial vessels.
For the patient with a nasal pack, prescribe analgesics for comfort and arrange ENT follow-up in 3 days. The role of prophylactic systemic antibiotics in patients who have nasal packs is not well established with wide variations in practice.
All patients requiring a posterior pack should be admitted because of the risk of airway obstruction and subsequent hypoxemia and dysrhythmias. Supplemental oxygen is administered once the pack is placed. Patients who have sustained significant blood loss or who have abnormal vital signs or concerning comorbidities, including coagulopathies, should be hospitalized.
Finally, those with refractory epistaxis despite the above measures are admitted for vessel ligation or selective arterial embolization. In the past several years, there has been a significant expansion in the number of options available to treat epistaxis.
Traditional strategies such as nasal packs have been supplemented by the modern technology of hemostatic agents producing less patient discomfort, improved efficacy, fewer complications, and reduced requirement for emergent ENT consultation. Gilman is an assistant professor in the division of emergency medicine at Medical University of South Carolina, Charleston.
Medical Editor Dr. Robert C. Solomon is an attending emergency physician at Trinity Health System in Steubenville, Ohio, and clinical assistant professor of emergency medicine at the West Virginia School of Osteopathic Medicine. In accordance with the Accreditation Council for Continuing Medical Education ACCME Standards and American College of Emergency Physicians policy, contributors and editors must disclose to the program audience the existence of significant financial interests in or relationships with manufacturers of commercial products that might have a direct interest in the subject matter.
Gilman and Dr. Solomon have disclosed that they have no significant relationships with or financial interests in any commercial companies that pertain to this educational activity. Each physician should claim only those credits that he or she actually spent in the educational activity. ACEP makes every effort to ensure that contributors to College-sponsored programs are knowledgeable authorities in their fields. Participants are nevertheless advised that the statements and opinions expressed in this article are provided as guidelines and should not be construed as College policy.
Step 4: Inflate the cuff to provide a gentle, low pressure tamponade delivering the CMC fabric directly to the bleed site. Step 5: When there is sufficient pressure in balloon s , allow the patient to sit for minutes prior to discharge. Step 6: The patient may come back hours later to remove the device or they may see an ENT specialist for follow-up.
Ordering Information. The following is not an exhaustive list, but an overview of some of the more popular packs available. This may provide a temporary tamponade. If there is still brisk bleeding seen in the oropharynx, Deflate the foley and pass it into the nasopharynx, inflate it and pull it anteriorly so that it occludes the choana. This will usually redirect the flow of blood anteriorly instead of into the airway. Deflate the foley catheter and move it posteriorly into the nasopharynx so that it occludes the choana.
Apply the gelatin-thrombin matrix to the posterior nasal cavity while continuing to occlude the choana with the foley for 10 minutes. If there is no further bleeding, irrigate the nose with sterile saline to remove any excess thrombin matrix. Image 1 : As seen here, Surgicel comes in sheets that may be folded or cut to size for placement as needed. Image 2: Nasopore in its packaging.
Image 3: Nasopore in its packaging. Image 4: Floseal in packaging. Image 5: Floseal prepared in applicable matrix form. Syringe and applicator allow for some mid-posterior nasal application.
Temporary packing: Foley catheter, lamb's wool, strip gauze, merocel, Rhinorocket, Rapid rhino. These packings must be removed. The duration of packing is variable, but generally from days, and should include antibiotic prophylaxis to prevent toxic shock syndrome Augmentin or 2nd generation cephalosporin or sinusitis. Absorbable packing does not warrant antibiotic usage. In general our practice is to pack again if a patient re-bleeds with the first packing removal.
If the patient re-bleeds a second time then the next step is generally an OR procedure or IR consult for embolization. Image 6: The 4. Image 7: The packaging and protective wrapper removed, all three devices pre-water soaked with no air added.
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