Epistaxis

One of the most common presenting ENT complaints in the ED. It is very commonly tested in Part B & C of MCEM Exam.

Before we proceed, I would like to highlight some important points to remember for exam purposes:

• Most of the Bleeding is from Anterior Part, but always examine the throat
• Remember the Keisselbach's Plexus' anatomy (Little's area of nose)
• Ask for history of trauma, anticoagulant use, hair picking, HTN
• Check for BP
• Watch for Shock and resuscitate accordingly
• Patients with nasal packing or Foley in Nose DO NOT GO HOME.

The Little's Area is formed by Anastamoses of:

1. Anterior Ethmoidal Artery
2. Posterior Ethmoidal Artery
3. Sphenopalatine Artery
4. Greater Palatine Artery
5. Superior Labial Artery

Let us approach the OSCE Scenario now:

The patient appear to be anxious and may be in shock. The best way to approach the OSCE Station for Epistaxis would be to ask him to do the first aid steps like pinching the nose, ice cubes, sitting position, etcetera.
Reassure and Check for vitals.
If unstable, resuscitate with IV Fluids
If stable, ask brief history of event, drugs, medications, nose picking, URTI,  HTN, liver problems.

Then recheck if the bleeding has stopped. Look in the throat.
If bleeding has not stopped, wear PPEs and do a speculum examination, suction, and place Epinephrine-lidocaine gauze in the nose for 10 minutes. Recheck after removing the guaze and cauterize with AgNO3 sticks. If not successful pack the nose with NetCel geal Foam, and admit.

Bleeding	Stopped
·         Sit Up ·         Pinch firmly at the soft part of nose tip for 15 minutes ·         Place an Ice cube in patient’s mouth	·         Observe for 15 minutes & Discharge
·         Wear PPE (3Gs: Glasses, Gown, Goggles), Mask & Headlamp ·         Nasal Speculum ·         Suction Catheter & Remove Clot ·         Insert Cotton Wool Pledget soaked in 1:10000 Epinephrine and 4 % Lidocaine in nasal cavity and leave it for 15 minutes ·         Remove Swab and Cauterize with AgNO3 Stick (Do not Cauterize on both sides of septum and for not more than 10 seconds)	·         Observe for 15 minutes & Discharge with nasal antiseptic cream
·         Anterior Nasal Pack soaked in parafin or NetCel foam	·         Admit under ENT
·         Bilateral Nasal Pack anteriorly	·         Admit under ENT
·         Assume Posterior Bleed ·         Pack with Foley Catheter 16 F with Bulb inflated with 10 ml Saline	·         Admit under ENT