Author Archives: Scott McClain

Another nose picker….

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I had a case of epistaxis the other day so I thought it would be interesting to review the management here. All of the following information can be found in Tintinalli’s, and there are also some great instructions in Roberts and Hedges. Disclaimer: this is not a complete review of epistaxis, mostly just the management. You can review the pathophysiology/epidemiology/important historical aspects/etc in your reference of choice. Here we go:

The management starts with a good physical exam. You need to figure out whether this is an anterior or posterior bleed. Posterior bleeds are much rarer, but are more difficult to control and usually bleed a lot more and require ENT assistance. The right equipment is essential.

Find a mask with a shield, a good light source, a nasal speculum, some 2×2 gauze, and some bayonet forceps. Position the patient upright and have them blow all the clots out of their nose (you might want to step back for this part). Using your equipment you’ve already laid out, look into the nose to see if you can identify the bleeding. Most cases are anterior bleeds, so you will likely see the source of bleeding (usually Kiesselbach plexus in the anterior septum). Spray some oxymetazoline or phenylephrine in the affected naris (or both if it’s not clear) to constrict the vessels. Now it’s time for direct pressure. Some hospitals have commercial devices that will do the work for you. If not, you can tape 2 tongue depressors together starting from one end and going about halfway, leaving the other end open. This can then be used to pinch the patient’s nose closed. Leave undisturbed for 15 minutes…..

Congratulations! You’ve just put a stop to most cases of epistaxis. If you’re not that lucky, it’s time to escalate. If you’ve identified the source of bleeding, you can try silver nitrate. Provide analgesia by soaking your gauze in a 1:1 mix of your vasoconstrictor and 4% Lidocaine and placing it in the anterior nose for a few minutes. Then, go back and cauterize with the silver nitrate. Avoid more than 3 attempts, and never cauterize both sides of the septum.

Still bleeding? Well, nevermind that busy ED you’re running, or the multiple ambulance crews dropping off more patients. Time to try a last ditch move before packing. You can try Gelfoam or Surgicel, or you can also try soaking some gauze in TXA and applying pressure over the site of bleeding with that. But if the patient continues to bleed, it’s probably time to pack…

Anterior nose packing can be done in multiple ways. Many EDs have the Rhino Rocket, or some other form of anterior nasal balloon. You insert these along the floor of the nasal cavity, and gently inflate with air (don’t use saline in case it ruptures). Other types of anterior packs have a sponge material which will expand inside the nose once it contacts the blood. You can also add a few mLs of saline to help it along. If the bleeding continues, you may try anterior packing the other naris. If you are unfortunate and work in an ED that does not have these devices, you will need to use strip gauze to fashion your own pack (again, great pictures in the references mentioned above).

If you’re still bleeding, it’s probably time to call for help. Continued bleeding despite the above measures suggests a posterior bleed. You can perform a posterior nasal pack while waiting for your specialist, or if you do not have ENT available. There are more commercial devices available that are longer and have an additional balloon for posterior packing. If you don’t have this available, you can use a 14 French foley catheter. Anesthetize the nose once again as before. Cut off the distal end of the foley past the balloon. Lubricate the end with Lidocaine gel, and advance along the floor of the nasal cavity, continuing until you can see it in the oropharynx. Now inflate the balloon with 7 mL of air, and retract a few centimeters to lodge it in the posterior nasopharynx.

Dispo: If anterior bleeding has been controlled, patient may be discharged with ENT followup. If packing is in place, antibiotics are controversial. Consider starting Augmentin to cover for Staph aureus and toxic shock syndrome. Posterior packs need to be admitted for further management by ENT.

Solid work! There are only 6 new ones to pick up…..

Limping toddler

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Nothing crazy here, just some EM bread and butter. I’ve had a couple of these at Children’s, and each time (with two different attendings), I’ve been told that the adult EM residents seem to overlook this, or not have any idea that it’s a thing, which is kind of embarrassing.

The patient is a 22-month-old male who presents with difficulty walking. Mom states that the child was walking fine until this morning. Since then, he has not been wanting to put weight on his right leg. Mom does not recall any injury. The child is otherwise well, no signs/symptoms of illness, and he has no medical problems.

On exam, the child will not put weight on his right leg when forced to stand. The extremity is well perfused, and there are no signs of trauma. He has no point tenderness, so it is not clear where he is hurting, but does seem to have pain when the foot is grasped and rotated internally and externally.

Discussion: In the toddler with a possible lower extremity injury, it may be difficult to localize where the child is having pain. If there is a question, the entire extremity should be imaged (though you should try to localize the problem area if possible). In this case, we suspected a toddler’s fracture, so a 3 view tib/fib was obtained. This is an important learning point: many times, the fracture line will only be visible on the oblique view, so it is necessary to get 3 views. In this patient, the xray was negative (as were other films of the leg). We diagnosed the child with a toddler’s fracture, placed him in a short leg splint with stirrups, and discharged him with orthopedics follow up.

A toddler’s fracture is a spiral fracture of the distal tibia which usually occurs by the same mechanism as an adult spraining an ankle. Sometimes it is a clinical diagnosis, not visible on X-ray. There is debate in the literature about immobilization in this case; some say it is necessary, some say it’s not. The culture at Norton Children’s seems to be immobilization. Regardless, the child should follow up in 1 week for definitive diagnosis, either with repeat plain films, or possibly MRI or bone scan. If there is a visible fracture on plain films in the ER, the child should be placed in a short leg splint with knee immobilizer and follow up with orthopedics in 72 hours.

Just another overdose…..right?

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20 yo M with unknown PMH comes in to room 9 with AMS and tachycardia to the 180s. Per EMS, he had been found down in his apartment, with crack cocaine pipes and other drug paraphernalia around him. He was found to be tachy as mentioned, as well as febrile with a temp of 103 axillary.

When he arrived in room 9, his HR was still in the 170s-180s. Blood pressure normal. He was pale, diaphoretic, and looked sick. He was speaking inappropriate words and would localize pain, GCS 12. Pupils dilated and briskly reactive. Rectal temp 104.1. CXR normal. Started IVF bolus and placed ice packs to the groin and axillae. Also gave Ativan as this was likely a stimulant overdose.

First EKG showed SVT at 180 BPM. After 2L of crystalloid and ativan, a repeat EKG showed sinus tachy at 140. The pt’s mental status was unchanged. The iStat showed a lactate of 13.

The plan was to place a rectal probe and monitor his temp, give him more fluids and Ativan prn, and re-assess later. I thought this was 100% an overdose. No problem.

About 2 hours and who knows how many room 9s later, I go to review his labs. I haven’t heard anything from nursing other than him continuously pulling out his rectal thermometer probe, so all must be well…Turns out he has a WBC of 44,000. Lactate has trended down, but he is still febrile to 102. This is when it hits me that maybe the guy who I’ve been treating for stimulant overdose is actually septic? His CXR and UA were normal, but maybe he has meningitis or encephalitis and that’s the reason for his mental status? Maybe I’m now 2 hours late with ABx?

I suppress the awful feeling in my stomach and go re-evaluate the pt. His mental status is unchanged from when I saw him in room 9. At least now his HR is in the low 100s. Given his mental status and tenuous vital signs, I know this patient is going to have to come in to the MICU. He’s going to need a head CT and an LP to rule out meningitis. I gave him antibiotics and called MICU. They evaluated the patient, and they agreed.

I chart checked the patient the next day. His LP was normal. His mental status improved overnight and he was transferred to the floor. Turns out this actually was likely all tox-related, but I thought it was a good learning point nonetheless. Sometimes it’s convenient to go down the path you’re led to by EMS or by nursing. Not only is it easy, but it’s usually the right path anyway. The stroke buzzer goes off and you immediately get your quick assessment over with so the patient can go to CT and stroke can do their thing. EMS tells you they found the patient in a house with drug paraphernalia, so you run with that.

But it’s important to keep the differential wide open when you first see a patient. At least consider less likely and less obvious possibilities. At some point, you’ll catch something that you otherwise would have missed until it was too late.