Nice job as usual. Thought you could mention the Pepper paper that Rick and Jerry did on EMA last October that showed no benefit with prophylactic antibiotics in patients that were packed. Not definitive but worth a mention.
Another tip recently mentioned on EMRap recently was that when cauterizing nose to cauterize posterior to bleed source before going for bleed source. I have been using this tip and it has led to much less incidence of me causing bleeding by attempted cautery.
I rarely have to insert painful RhinoRockets or Merocel tampons since I started liberally using Surgicel absorbable hemostats when treating epistaxis. These can be applied to the anterior septum before or after silver nitrate cautery. I usually use 2-3 of the small ones and end up only packing about 5% of nosebleeds. Mark S.
As you commented it is impossible to use silver nitrate cautery on a bleeding septum so my own practice is to use adrenaline soaked pledgets of cotton wool applied to the area and have the patient squeeze the nose over it for 10 minutes. I then re-examine and sometimes have to repeat until haemostasis achieved so I can cauterise. Occasionally that vessel will just not stop bleeding and I can't cauterise so have used a small dose of lignocaine with adrenaline injected into the base of the bleeding vessel . I use an insulin syringe with 29G needle and only need <0.1 ml. Seems to be well tolerated and effective. I can then cauterise.
For anterior nasal septal bleeds in 15 years of EM practice I have personally found cautery to be ineffective. If the bleeding stops on your shift it will likely return on your partners. To me the benefit of packing an anterior bleed is it prevents pts finger from reaching the wound in the next 48 hours allowing it time to heal.
I agree with Sean, I try to never send a pt home without SN cautery or they just bounce back. I have a great Algorithm for nose bleeds.
Whether they are actively bleeding or not.
1) Get real Cotten Gauze to the bedside with viscous lidocaine and neosynephrine spray, foreceps and nasal speculum. 2) Unfold the Gauze (the real gauze. At my shop I can only get it as pre-rapped sterile Gauze, the synthetic gauze only has 2 folds and does not work well) hold the gauze by a corner and saturated it with viscous lido. then spray it down with the Neo. (Both are vasoconstrictors and the lido. will numb the mucosa for future cautery.) 3) Have them blow their nose to get clots out. 4) Use forceps to pack the bleeding side with the Soaked Gauze you just made. Have the pt pinch there nose with another gauze. (I like to wrap the gauze under the nostrils so lido. does not drip down into the pt mouth) 5) Tell the pt you will be back in 20-30 min. If I am not back, hit the call bell.
To this point about 2 mins have past, and I am taking my Hx while preparing the gauze. I will not even exam the nares other then to see which side is bleeding. I find that if there is active bleeding you can't see anything. If it stopped but was recently bleed there is only dried blood and clots and you cannot identify the source anyway.
6) Go see another Pt. 7) Return to the Rm and remove packing. (90% of the time you will have a clean nares. All the clots and dried blood come out with the Medicine soaked gauze.) You now also have an numbed mucosa for SN cautery. 8) Examine with nasal speculum and cauterize with silver nitrate if the source it anterior.
About 90% of the time I am done with the case. Although I usually watch them for 45 min to make sure they do not re-bleed.
9) Very rarely will an anterior bleed still be pumping at this point. (These are usually Plavix or Coumadin Pts) At this point I will have the pt pinch again and call for Cocaine. I will use Q-tips to apply Cocaine directly to the source to stop the bleeding only momentarily to get the SN to the tissue.
If this does not work I may repeat from step 1. If that does not work they get a commercial packing devise, Abx and FU with ENT. Although I can avoid this in about 95% of my pt.
If at step 8. I can't cauterize anything and the bleeding has stopped, I get concerned that there was a posterior bleed, because, the first 7 steps almost always create conditions for a great exam of the anterior nares. I will watch them longer before discharge and usually expect them to bounce back. But if the bleeding is stopped I will not place at posterior balloon.
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Brad S. - April 8, 2013 3:57 PM
Nice job as usual. Thought you could mention the Pepper paper that Rick and Jerry did on EMA last October that showed no benefit with prophylactic antibiotics in patients that were packed. Not definitive but worth a mention.
Aaron B. - April 8, 2013 4:01 PM
Definitely Brad, thanks.
Paul B., M.D. - April 11, 2013 5:46 PM
Another tip recently mentioned on EMRap recently was that when cauterizing nose to cauterize posterior to bleed source before going for bleed source. I have been using this tip and it has led to much less incidence of me causing bleeding by attempted cautery.
Todd C. - April 14, 2013 11:08 AM
In my experience, this will stop the vast majority of anterior nosebleeds:
http://academiclifeinem.blogspot.com/2011/07/trick-of-trade-epistaxis-control-with.html
Mark S. - April 17, 2013 1:10 PM
I rarely have to insert painful RhinoRockets or Merocel tampons since I started liberally using Surgicel absorbable hemostats when treating epistaxis. These can be applied to the anterior septum before or after silver nitrate cautery. I usually use 2-3 of the small ones and end up only packing about 5% of nosebleeds. Mark S.
Jan S. - April 19, 2013 2:41 PM
These are all great comments and tips. Thanks for adding all this info!
Scott p - May 24, 2013 7:39 PM
As you commented it is impossible to use silver nitrate cautery on a bleeding septum so my own practice is to use adrenaline soaked pledgets of cotton wool applied to the area and have the patient squeeze the nose over it for 10 minutes. I then re-examine and sometimes have to repeat until haemostasis achieved so I can cauterise. Occasionally that vessel will just not stop bleeding and I can't cauterise so have used a small dose of lignocaine with adrenaline injected into the base of the bleeding vessel . I use an insulin syringe with 29G needle and only need <0.1 ml. Seems to be well tolerated and effective. I can then cauterise.
Sean G., M.D. - May 26, 2013 2:24 PM
For anterior nasal septal bleeds in 15 years of EM practice I have personally found cautery to be ineffective. If the bleeding stops on your shift it will likely return on your partners. To me the benefit of packing an anterior bleed is it prevents pts finger from reaching the wound in the next 48 hours allowing it time to heal.
Richard S., M.D. - July 1, 2013 1:10 PM
I agree with Sean, I try to never send a pt home without SN cautery or they just bounce back.
I have a great Algorithm for nose bleeds.
Whether they are actively bleeding or not.
1) Get real Cotten Gauze to the bedside with viscous lidocaine and neosynephrine spray, foreceps and nasal speculum.
2) Unfold the Gauze (the real gauze. At my shop I can only get it as pre-rapped sterile Gauze, the synthetic gauze only has 2 folds and does not work well) hold the gauze by a corner and saturated it with viscous lido. then spray it down with the Neo. (Both are vasoconstrictors and the lido. will numb the mucosa for future cautery.)
3) Have them blow their nose to get clots out.
4) Use forceps to pack the bleeding side with the Soaked Gauze you just made. Have the pt pinch there nose with another gauze. (I like to wrap the gauze under the nostrils so lido. does not drip down into the pt mouth)
5) Tell the pt you will be back in 20-30 min. If I am not back, hit the call bell.
To this point about 2 mins have past, and I am taking my Hx while preparing the gauze. I will not even exam the nares other then to see which side is bleeding. I find that if there is active bleeding you can't see anything. If it stopped but was recently bleed there is only dried blood and clots and you cannot identify the source anyway.
6) Go see another Pt.
7) Return to the Rm and remove packing. (90% of the time you will have a clean nares. All the clots and dried blood come out with the Medicine soaked gauze.) You now also have an numbed mucosa for SN cautery.
8) Examine with nasal speculum and cauterize with silver nitrate if the source it anterior.
About 90% of the time I am done with the case. Although I usually watch them for 45 min to make sure they do not re-bleed.
9) Very rarely will an anterior bleed still be pumping at this point. (These are usually Plavix or Coumadin Pts) At this point I will have the pt pinch again and call for Cocaine. I will use Q-tips to apply Cocaine directly to the source to stop the bleeding only momentarily to get the SN to the tissue.
If this does not work I may repeat from step 1. If that does not work they get a commercial packing devise, Abx and FU with ENT. Although I can avoid this in about 95% of my pt.
If at step 8. I can't cauterize anything and the bleeding has stopped, I get concerned that there was a posterior bleed, because, the first 7 steps almost always create conditions for a great exam of the anterior nares. I will watch them longer before discharge and usually expect them to bounce back. But if the bleeding is stopped I will not place at posterior balloon.