ENT in the ED

 

The gist of my approach to epistaxis is this:

If the patient is bleeding the first thing to do is to stop it. Get the patient to apply first aid (which means holding their nose firmly as far back on the vestibule as possible- you will need to show them as they will invariably jsut be poking and mopping at their nostril openings with a tissue or spitting noisilly into a bowl). Then get yourself set up for cautery and/or pack (see below).

If the patient is not bleeding but the bleeding nose was enough to bring them to hospital then it will bleed again soon enough. Set up for cautery/pack anyway. This is in adults. Kids get bleeing noses a lot once they learn to get their fingers up there but they don't usually come to hospital for it as someone jsut tells them to keep their finger out for a while and it settles down.

My approach to cautery/packing of the non-bleeding patient is the same as the bleeding one because once you start the bleeding will often start up again too.

Setting up:

Make sure you have a good light source (head lamp is best) and a nasal spec. Have suction, an em-bag and some tissues handy and get a gown for you and put a sheet or bluey over the patient's chest. Warn the patient that you will need to be cruel to be kind and that you will do what needs to be done as quickly and comfortably as you can but that it might be a bit unpleasant. Tell them that you are going to ignore them if they grimace or make unhappy noises but that if they need you to stop they must just say "stop" and you will do so. If your patient knows they have a "safe word" they will tolerate a lot more. Have the patient blow their nose properly once to get the big jellied clots out of the way. Spray the nose, then unroll a cotton wool ball and soak it in cophenylcaine and put it up each nostril while you set up everything else (pack, AgNO3 sticks, lamp, blunt  forceps). 

Getting a view:

Pull out the cotton wool and suction out clot int he nose. Wrap a little cotton wool around the end of your forceps and soak it in local and then use this to further toilet the nose. This is also useful for applying direct pressure after cautery. Only once the nose is clean can you get access to Little's area for cautery or even confirm a bleeding point.

Cautery:

Roll the end of a AgNO3 stick over Little's area. I once thought you just held it in the middle of the bleeding spot like a spot welder. What this does is digs a nice deep hole that bleeds like mad around the edges. By rolling it over the surface you can cauterise the capillary network that is feeding Little's area.

Wait a moment for the reaction to occur and then apply some direct pressure with your co-phenylcaine soaked cotton wool on the end of your forceps. this will help stop the early bleeing you sometimes get after cautery.

Always apply some vaseline or chlorsig ointment after cautery and have the patient sit quietly for an hour or so. It is quite reasonable to use SSOU for post-procedure observation in case of early re-bleed. If there is no re-bleed the patietn can be discharged with some ointment and a decongestant spray. Re-bleeding means a pack.

Pack:

If there is a rebleed or if the bleeding is too much and you can't manage to cauterise (although if you take a stepwise approach like I have outlined above this will usually not be the case with anterior bleeds) or if it is a posterior bleed you will need a pack. Be familiar with what you have in your ED but try to make sure it is not Bipp gauze as this is about 20 years out of date. Merocel tampons are ok but pretty nasty. Rapid Rhino is amazing but pricey. Just follow the instructions in the packet. They even make a long one for posterior bleeds. NEVER use plain ribbon gauze- the blood sets like concrete and it may take surgery to remove it.

Adjuncts in difficult cases:

Reverse the warfarin. This is a common culprit and it may need to be switched off for a day or so with some prothrombinex.

Replace platelets. This is usually only an issue in patients with myelodysplastic disorders.

Lower the BP. IV morphine is a great drug in this situation. It eases the pain of what you are doing to the patient, it eases their anxiety and it drops their (often very high) BP so the bleeding can stop.

Inject some local with adrenaline into the greater palatine foramen (just medial to the 3rd molar in the roof of the mouth toward the back of the hard palate). Seriously! You can find it easily enough with a bent 25G needle. Topicalise the roof of the mouth with some cophenylcaine and then raise a bleb of local under the mucosa so you can poke around and find the hole. When you do, avaoid an intraterial injection by aspirating first and then inject. The bloodflow is from nose to mouth so you need to get up into the foramen to have a good effect as you want to contrict the arterioles coming off the artery in the floor of the nose. When they are soaking though the packs and nothing seems to work this has never failed me.

Don't forget the rest of the patient:

Large or recurrent bleeds should prompt a check of the Hb, especially in the elderly or others with compromised bone marrow.

Make liberal use of short stay or admission to hospital for observation for 4-24 hours, especially after a pack.

 

As for the other ENT infections:

Best just read the powerpoint but some key pearls are:

If the patient can't lie flat, worry about their airway.

If they patient can't look up and down easily think about retropharyngeal infections or tracheitis.

If the patient is toxic it is not croup.

If the patient is too old for croup or it just doesn't seem to fit, think bacterial tracheitis or retropharyngeal abscess.

If you are worried about an upper airway remember :NEVER screw up an upper airway infection all on your own. Share the love with the ENT surgeon, the general surgeon, the anaesthetist, the paediatrician. You can share a taxi to the supreme court that way.