Emergency Medicine · Year 3 · from Emergency Medicine

Case 3: Posterior Epistaxis - The Bleeding That Won't Stop

Patient Demographics

• Age: 72 years
• Sex: Female
• Occupation: Retired nurse

Chief Complaint

"My nose won't stop bleeding and I'm swallowing a lot of blood."

History of Present Illness

A 72-year-old female presents with profuse epistaxis for 2 hours that has not responded to home measures (pinching nose, ice). She reports swallowing significant amounts of blood and has vomited once (bloody emesis). She has a history of hypertension and takes aspirin daily for cardiovascular protection. The bleeding began spontaneously while watching television.

Initial Assessment

ESI Level: 2 - Potential significant hemorrhage

First Impression:

• Appearance: Anxious, blood around mouth and in basin
• Work of breathing: Normal
• Circulation: Pale, tachycardic

Vital Signs:

• Heart rate: 104 bpm
• Blood pressure: 188/102 mmHg
• Respiratory rate: 18 breaths/min
• SpO2: 96% on room air
• Temperature: 36.8C
• GCS: 15

Primary Survey

Airway:

• Patent but active bleeding with swallowing
• Position patient leaning forward to prevent aspiration

Breathing: Normal effort Circulation: Tachycardic, pale, active hemorrhage Disability: Alert Exposure: Blood on clothing, in basin

Classification of Epistaxis

This Patient - Features Suggesting POSTERIOR Epistaxis:

• Bilateral bleeding
• Blood draining into pharynx
• Profuse, not stopping with pressure
• Elderly with hypertension on anticoagulant

Immediate Management

Initial Steps:

1. Universal precautions (blood exposure risk)
2. Position: Sitting upright, leaning forward
3. Have patient blow nose (clear clots)
4. Suction equipment ready
5. IV access, type and screen
6. Apply topical vasoconstrictor

Topical Vasoconstriction:

• Oxymetazoline (Afrin) soaked cotton pledgets
• Place in nasal cavity, apply direct pressure x 15 minutes
• Alternative: Cocaine 4% or lidocaine with epinephrine

Nasal Examination

After vasoconstriction and suctioning:

• Anterior rhinoscopy performed
• No clear anterior source identified
• Blood seen trickling posteriorly
• Bilateral bleeding (posterior source likely)

Finding: No anterior source identified = POSTERIOR EPISTAXIS

Secondary Survey

SAMPLE History:

• Symptoms: Profuse epistaxis 2 hours, swallowing blood
• Allergies: Sulfa
• Medications: Aspirin 81mg daily, lisinopril, hydrochlorothiazide
• PMH: Hypertension, hyperlipidemia, no bleeding disorders
• Last Meal: 3 hours ago
• Events: Spontaneous onset

Risk Factors:

• Hypertension (uncontrolled)
• Aspirin use
• Elderly (fragile vessels)

Management Progression

Step 1: Anterior Packing (if posterior suspected, may bridge to posterior)

• Merocel (expandable sponge) or Rapid Rhino placed
• Bleeding continued despite bilateral anterior packing

Step 2: Posterior Packing Required

Posterior Packing Options:

1. Posterior epistaxis balloon catheter (Epistat, Rapid Rhino posterior)
2. Foley catheter technique
3. Formal posterior gauze packing (requires sedation)

This Patient:

• Bilateral posterior packing with balloon catheters placed
• Posterior balloon inflated with 7-10mL saline
• Anterior cuff inflated
• Bleeding controlled

Diagnostic Testing

Labs:

• CBC: Hgb 10.2 (likely hemodiluted, check baseline was 12.8)
• Platelets: 234,000
• PT/INR: 1.0
• PTT: 32 seconds
• Type and screen: O positive

Hemoglobin concerning for significant blood loss - baseline was 12.8 (per patient's knowledge)

Additional Management

Blood Pressure Control:

• Epistaxis and hypertension: Control BP, but avoid hypotension
• Goal: <160 systolic
• Labetalol 10mg IV given
• BP improved to 152/88

Aspirin:

• Held during acute bleeding
• Discussion with cardiology re: resumption

Transfusion:

• Hemoglobin 10.2 in asymptomatic patient with controlled bleeding
• Not transfused; serial monitoring

Admission Criteria for Posterior Epistaxis

ALL patients with posterior packing should be admitted:

• Airway monitoring (packing can dislodge, cause obstruction)
• Hypoxia risk (nasopulmonary reflex)
• Rebleeding risk
• Cardiac monitoring (vagal response)

Additional Indications:

• Hemodynamic instability
• Significant blood loss
• Failed outpatient management
• Need for blood transfusion

Hospital Course

Day 1:

• Posterior packing in place
• No rebleeding
• Hemoglobin stable

Day 2:

• Packing removed by ENT
• No rebleeding after removal
• Observed for 6 hours

Day 3:

• Discharged home
• Blood pressure medications adjusted
• Held aspirin x 1 week (cardiology approved)
• Saline nasal spray
• Avoid nose blowing, straining
• ENT follow-up in 1 week

When to Involve ENT/IR

ENT Consultation:

• All posterior epistaxis
• Failed anterior packing
• Recurrent epistaxis
• Suspected nasal mass
• Need for examination under anesthesia

Interventional Radiology:

• Refractory posterior epistaxis
• Sphenopalatine artery embolization highly effective
• Alternative: Surgical ligation

Teaching Points

1. Position matters: Sit upright, lean forward to prevent aspiration
2. Anterior vs. posterior: Posterior = blood in pharynx, bilateral, elderly with HTN/anticoagulation
3. Vasoconstriction first: Oxymetazoline or topical epinephrine
4. Step-wise escalation: Direct pressure → anterior packing → posterior packing → ENT/IR
5. Admit all posterior packing: Airway risk, hypoxia risk, rebleeding risk
6. Control blood pressure: But avoid hypotension; SBP <160 reasonable target
7. Check hemoglobin: Epistaxis can cause significant blood loss
8. Anticoagulation management: Hold if possible; discuss risk/benefit with cardiology

Clinical Image

Image Description: Illustration demonstrating placement of a posterior epistaxis balloon catheter with the posterior balloon inflated in the nasopharynx and anterior balloon inflated in the nasal cavity to tamponade posterior bleeding sources.

Attribution: Image from Wikimedia Commons, Nasal packing for epistaxis. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Blausen_0061_AnteriorNosePacking.png

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