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.

Otoscopy

Performing an Otoscopy is an essential skill to master, especially while caring for pediatric patients, or in the fast track zone of our ED. It has been tested in the previous MCEM Part C Examination as a teaching station too. Although, we may have been doing it several times in our shifts, but this video would help us in learning to do it the right way.

(Video Courtesy: Oxford Medical)