Interesting case of Epistaxis
Tue, 05/05/2020 - 11:29am
Editor:
HPI: 85 y.o. Male PMH Afib (on Warfarin) p/w epistaxis
- Constant x6 hours
- Bilateral nares
- No relief with applying pressure or with vasoconstrictors (Afrin) PTA
PHYSICAL EXAM
Vitals: BP 140/81 | Pulse 73 | Resp 18 | SpO2 96%
HENT: Epistaxis bilateral nares - unable to visualize source. Blood within oropharynx
DDX
- Anterior vs posterior epistaxis
- Acute blood loss anemia
WORK UP (LABS)
- CBC
- PT/INR
INITIAL PLAN
- Attempt to visualize source - have patient blow nose to blow out any clots
- Nasal speculum
- If no active hemorrhage and source visualized → silver nitrate cautery
- Oxymetazoline (Afrin) nasal spray + pressure for 10 minutes
- Oxymetazoline (Afrin) + TXA soaked gauze for 20 minutes
LAB RESULTS AND REASSESS
- HGB 8.6
- INR 4.8
FINAL PLAN
- Warfarin (Coumadin) reversal → 2.5 mg phytonadione (vitamin K1)
- TXA soaked 5.5 cm Rhino Rocket
- RESOLVED
- IF not → posterior packing required
- Admitted for observation, repeat CBC, INR, ENT consult
- Prophylactic antibiotics for TSS??
- Controversial!!
- Options: Cephalexin, Amoxicillin/clavulanate, Clindamycin
KEY POINTS
- Anterior epistaxis (most common!) → Kiesselbach’s Plexus
- Multiple options: TXA nebs, soaked gauze / pledgets (TXA, lidocaine w/ epinephrine, tetracaine, cocaine), nasal tampons, nasal balloons
- Posterior epistaxis
- Foley cath or other balloon devices
- Requires ICU for cardiac monitoring given risk for bradydysrhythmias
- Consider anticoagulation reversal