Cases from the Field – June Edition
CASE OF THE MONTH – JUNE 2021
EMS providers respond to a 59-year-old male with a history of hereditary hemorrhagic teleangiectasia (malformations of blood vessels) who was at a restaurant with family when his nose started to bleed. Despite applying direct pressure for 15 minutes, his bleeding continues. He and his family report that he has nosebleeds often due to his lifelong medical condition. EMS notes profuse bleeding from both nares and he is spitting red blood and clots from the mouth. Initial vitals are BP 84/45, HR 120, RR 18, O2 Sat 99% on room air.
The initial priorities in this patient are addressing the “ABCs”, focusing on ensuring an airway, breathing, and identifying and initiating treatment for hemorrhagic shock. This patient has significant active bleeding and is hypotensive due to blood loss (hemorrhagic shock). Although he is may be able to protect his airway currently, if he were to become less alert or lose consciousness due to poor perfusion, his airway could be compromised due to the bleeding. His hypotension must be addressed immediately. The primary provider impression for this patient would be Shock / Hypotension (SHOK) and he should be managed in accordance with TP-1207, Shock / Hypotension, focusing on hemorrhage control and volume resuscitation. The secondary provider impression is Epistaxis (NOBL), managed in accordance with TP-1226, ENT / Dental Emergencies.
On initial assessment, the patient has a manageable airway; it is patent and he is breathing adequately. Because the patient is in shock, high-flow Oxygen 15L/min is indicated. Because the patient cannot tolerate a NRB mask due to the active bleeding, blow-by Oxygen at 15L/min is initiated. Vascular access with a large bore 16G catheter is obtained and Normal Saline 1L IV rapid infusion is started. Hemorrhage control is attempted with continued direct pressure.
In accordance with TP-1226, ENT / Dental Emergencies, one should attempt to control bleeding by pinching the nose just distal to the nasal bone with the head in a neutral position and the patient sitting forward in high Fowler’s position, leaning forward.
Figure 1. Applying direct pressure just distal to the nasal bone. Photo credit: Alter, H. Approach to the adult with Epistaxis. https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis. Accessed June 9, 2021.
Figure 2. Applying direct pressure just distal to the nasal bone. Photo credit: Alter, H. Approach to the adult with Epistaxis. https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis. Accessed June 9, 2021.
This patient is hypotensive; if he cannot tolerate sitting upright due to poor perfusion, consider having him lay on his side to protect the airway, with the head of the gurney slightly elevated while maintaining direct pressure.
Sometimes, it is difficult for patients to cooperate to maintain direct pressure for the sustained period of time needed for hemorrhage control. The patient or provider may also feel the need to frequently release pressure to assess if bleeding has stopped. Direct pressure without release should be maintained for at least 10 minutes. If a patient finds it difficult to comply with continuous direct pressure and EMS personnel are not able to assist continuously, a two-tongue depressors and tape technique can be used to apply pressure:
Wrap tape around the end of two tongue depressors such that a firm clamp is created on the opposite ends of the tongue depressors. Apply the tongue depressors to the nose to apply direct pressure just distal to the nasal bone.
Figure 3. Direct pressure clamp created with tongue depressors and tape. Photo credit: https://www.theresusroom.co.uk/epistaxis/
Many blood vessels supply the nose. Figure 3. Arteries that supply Kisselbach’s plexus (responsible for anterior nose bleeds). Credit: https://commons.wikimedia.org/wiki/File:Arteries_of_the_Nose.
Epistaxis results from disruption of this blood supply. Most nosebleeds are from the anterior nose. Posterior bleeding can occur as well and may be difficult to control with direct pressure alone. Common reasons for epistaxis include nose picking, mucosal dryness, foreign bodies, and nasal trauma. Patients that are anticoagulated are at high risk for nosebleeds. One should obtain a history of anticoagulant use. Hypertension is associated with an increased risk for epistaxis though a causal relationship has not been demonstrated.
Bleeding disorders are also a reason for recurrent epistaxis. Hereditary hemorrhagic teleangiectasia (also known as Osler-Weber-Rendu disease), as presented in this case, frequently presents with epistaxis that is difficult to control. These patients have a genetic disorder that affects blood vessels causing arteriovenous malformations (AVMs) throughout the body. AVMs are easy to rupture resulting in hemorrhage.
Figure 4. Arteriovenous malformations. Source: American Stroke Association
Other medical conditions that predispose patients to epistaxis due to bleeding abnormalities include platelet disorders and hemophilia.
The patient is able to tolerate sitting upright in High Fowler’s position and maintains direct pressure to his nose continuously. After 500cc of Normal Saline, vitals signs improve to BP 98/56 HR 114 RR 18 O2 Sat 99%. Normal Saline is continued. Despite continued direct pressure, bleeding continues.
This patient is in hemorrhagic shock due to blood loss. Transport should be prioritized without delay. Once initial stabilizing measures are initiated including attempting hemorrhage control, airway management, and volume resuscitation, immediate transport is indicated.
The patient is transported to the Most Accessible Receiving (MAR) where attempts to control bleeding in the Emergency Department (ED) are initiated as well as continued volume resuscitation. While in the ED, a topical vasoconstrictor is placed in the nares and a balloon catheter is placed.
Figure 5. Balloon catheter for epistaxis. Credit: http://www.emdocs.net/emergency-department-management-posterior-epistaxis/
The patient’s hemoglobin is 6.4 g/dL and he requires a blood transfusion. The Otorhinolaryngologist (ENT) is consulted for further management and the patient is admitted to the hospital for management of the bleeding, ongoing resuscitation and airway observation. He is found to have a posterior nosebleed that ENT is able to ligate under endoscopy.
- The initial management priorities for epistaxis are addressing the “ABCs”, ensuring an airway, breathing and initiating volume resuscitation if signs of poor perfusion.
- Direct pressure should be applied to the nose just distal to the nasal bone for hemorrhage control. Position the patient appropriately to protect the airway.
- Most patients with epistaxis will not have significant blood loss; recognize that patients with significant blood loss leading to poor perfusion and shock should be prioritized for transport after immediate hemorrhage control and fluid resuscitation.
- Alter, H. Approach to the adult with Epistaxis. https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis. Accessed June 9, 2021.
- Simon, E. The Emergency Department Management of Posterior Epistaxis. http://www.emdocs.net/emergency-department-management-posterior-epistaxis/. Accessed June 9, 2021.
Author: Denise Whitfield, MD, MBA