22 June 2010

Drip Drip Drip

If you asked me, back in the oh-so-distant past when I was just getting started, what I'd like my Emergency Medicine blog to look like, I'd have described something that sounds like what Life in the Fast Lane looks like today.  Which is to say, it's a blog which is heavy on the education and academic stimulation but also full of off-beat humor, irreverence and attitude in addition to great story-telling (an absolute prerequisite for an EM blog).

I admit I don't get more than half their jokes, but that's to be expected: they're AUSTRALIAN, for pete's sake. But the incomprehensible humor just adds to their charm, just like their accents, weird musical instruments and their propensity for knives:


Anyway, today's post caught my interest and I thought I would riff on it a bit.

Nosebleeds.

Some people hate them; I don't mind them, fortunately.  I once had one of my partners offer to deal with the 300-pound patient with chronic pelvic pain if I would take the nosebleed in room 18.  (You can imagine how quickly I grabbed that deal!)  Go on over to Life in the Fast Lane and do some regular book-learning about nosebleeds before you read on. It's worth the read, and I'll wait.  Go on!

(humming the Jeopardy theme song)

Ah great!  You're back! 

Now let me share some hard-won tips and tricks for managing nosebleeds in the real world.

1.  Physical exam lends little to the work-up. It's worth looking in the nose (barely) but it's all a god-awful bloody mess and you'll rarely see anything of value in an actively bleeding nose, so don't torture poor old ladies trying to decipher the source of the bleeding from the exam. Posterior bleeding does not mean a posterior source, by the way. In my world a "posterior" bleed is defined as a "bleed with a non-visualized source which doesn't stop with standard ER measures."

2. Afrin.  Use it and use lots of it. Afrin and compression will resolve 90% of ER nosebleeds (based on a study which I just imagined based on the last ten years of clinical practice).  If nothing else, Afrin will make your physical exam easier, if you insist on doing one.  No nosebleed should ever be un-Afrinized.

3. Vital signs.  The most awesomely humiliating event of my residency was when I called the ENT resident to the ER for a nosebleed which we simply could not stanch. He showed up and as he wandered into the room, he called out over his shoulder, "I assume you did something about that blood pressure."   "That what?" I thought to myself as I picked up the chart.  The blood pressure was 230/120. Aye aye aye. The nurse snuck in and gave a dose of labetolol as the resident examined the patient.  Somehow the bleeding was easier to control thereafter. It may not be a proven cause of nosebleeds, but it's hella hard to control the bleeding with that sort of pressure driving it.

4. Silver Nitrate.  Banish it to the dark ages. Compress or Pack. There is no in between.

5. Coumadin/Warfarin: The cause of most all the difficult bleeds. Forget Vitamin K; it won't help you in time, and FFP is really just for the crashing patient.  What do you do to stop the difficult coumadin-induced bleed?  The ER doctor is the master of "duct tape and baling wire" solutions and this is foremost among the situations in which ingenuity is called for.  What I do is pack the nose with DRY packing -- it doesn't matter much what you use. Merocel is common, the rapid-rhino balloon works OK, too.  Then once the packing is in, I immediately place the patient supine and slowly drip thrombin solution in to the packing.  The thrombin activates the clotting cascade, of course, and the packing keeps it close to the area that is bleeding, so the likelihood of developing functional clot in the anticoagulated patient is pretty good.  You can actually soak the rapid-rhino in the thrombin solution before you insert it. I hear thrombin is expensive so I use this only for the cases where I'm up a creek without the proverbial paddle.  But it has yet to fail me.

6.  Analgesia. Nasal packing hurts.  Seriously uncomfortable. I work like hell to avoid it. When I have to do it I want the nasopharynx seriously numb. High-pressure sprays like cetacaine blow right past the nasal area and provide incomplete relief.  I put a good 10cc of viscous lidocaine up there (the urojet applicator works particularly well for this purpose) and I leave it there for ten minutes.  Go and see the next patient while this absorbs. Better yet, it acts as its own lubricant while you insert the packing!  It still hurts, since there's a lot of bony pressure on the nasal turbinates, so I always still warn the patient it will be uncomfortable. But this gives better relief than any other method I have found.

7. "A" stands for airway. Bleeding that goes back down the pharynx will usually pass through to the stomach and cause harmless vomiting.  Once in a while, however, the posterior clot will extend, and it can get into the larynx. Assess the patient's voice, and LOOK into the posterior pharynx for a telltale "string" of clot heading south.  If present, get your MacGills and pull it out. It can be scary how much clot can accumulate in the trachea before the patient's airway closes off!

8. Check platelets if anything seems funny. I've twice diagnosed ALL presenting with nosebleeds.  Not all nosebleeds need blood work, but keep the thought in your head.

9. Check the tetanus. Nasal foreign body is a (rare) cause of tetanus. If you pack a nose, it's as good an opportunity as any other to update the tetanus immunization.  And don't forget the antibiotics. Toxic shock is a zebra complication, more commonly sinusitis due to imparied drainage can result from packing.

10. The most frustrating thing about nosebleeds is their propensity to recur.  If you get a bleed stopped without packing it, the chance is 50/50 they'll make it past the parking lot before it restarts. AMBULATE the patient around the department before discharge, and spend some precious bed-time observing the non-bleeding patient before discharge.  Bounce-backs are incredibly frustrating (especially at the end of your shift). So take a little extra time to be sure the bleeding is well and truly stopped before letting them go.  Also be sure to warn them against nose-picking or blowing for 24 hours. It's amazing -- patients have a nose full of clot and they want to extract that clot with their fingernails!  Leave it there until it's hardened and then and only then can you pick and blow your nose.  Otherwise, you'll be right back in a couple of hours.

Thanks for the great post, guys, and GO SOCCEROOS!

C'mon, it's not like the US has a chance, either.

4 comments:

precordialthump said...

Thanks Shadowfax,

It's always humbling to see LitFL get a mention on Movin' Meat - we're glad we can count you among our readers.

... and what a great riff - the bad bleeder sure can ruin a shift. Great to glean some insights from your experiences.

Cheers,
Chris

BTW, I presume the 50% of LitFL jokes you do get are those written by New Zealanders...

Anonymous said...

Every use 4% cocaine as a nasal swab or packing?
Numbs & vasoconstricts as well.

We used to compound it in the pharmacy from the powder, but its commercially available now.

Anonymous said...

The LitFL site is impressive, I'll give them that.

To the last comment: Also heard that intra-nasal cocaine is becoming more popular

John Ross said...

I don't think I ever actually had a nose bleed.

I loved the jeopardy music reference though. I often "do" that music(yes, aloud) while waiting for the card reader/cash register at checkouts.

On a couple of occasions someone has looked at me and said something like "oh, you do that too!"