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HEAD, EYE, EAR, NOSE, AND THROAT

EMERGENCIES

TREATMENT

■ Direct pressure
■ Expel clots (spit and blow).
■ Soaked pledgets (lidocaine plus oxymetolazine, neosynephrine, or
cocaine)
■ Cauterize with silver nitrate 5–7 seconds max, then apply surgicel or baci-
tracin ointment. Avoid cauterizing both sides of the nasal septum.
■ Oral antibiotics if packing placed
■ Anterior packing with <10-cm tampon; remove in 2 days

COMPLICATIONS

Sinusitis, toxic shock syndrome, septal necrosis, rebleed

Posterior Epistaxis

SYMPTOMS/EXAM

■ Fivetotenpercent of all nosebleeds
■ More common in older patients
■ Common causes: Atherosclerosis, coagulopathy, HTN
■ Source is from Woodruff plexus: Anastomosis of posterior nasal, posterior
ethmoid, sphenopalatine, and ascending pharyngeal arteries over the pos-
terior middle turbinate
■ Bilateral nasal bleeding, blood in the back of the throat, inability to visualize
source or stop bleeding with anterior pack suggests posterior source

TREATMENT

■ First try anterior epistaxis techniques.
■ Pack with posterior nasal gauze pack or 10-cm balloon tampon.

For traumatic nasal bleeding

that is continuous, consider

basilar skull fracture.

FIGURE 14.6. Arteries that contribute to anterior and posterior epistaxis.

(Reproduced, with permission, from Tintinalli JE, Kelen GD, Stapczynski SJ. Emergency
Medicine: A Comprehensive Study Guide, 6th ed.New York: McGraw-Hill, 2004:1477.)

Posterior

ethmoid

artery

Sphenopalatine

artery

Anterior

ethmoid

artery

Little area

(Kiesselbach

plexus)

Superior

labial artery

Greater

palatine artery

Four arteries of

Kiesselbach

PLExuS:

GreaterPalatine

SuperiorLabial

AnteriorEthmoid

Sphenopalatine

Most common site of bleeding

from the posteriorregion is

the posterior lateral branch of

thesphenopalatine artery.