A 78-year-old male with a history of atrial fibrillation on warfarin presents with epistaxis. Patient is having continuous bleeding at the bilateral nares as well as spitting up large amounts of blood into a bucket. Patient arrives as transfer from an outside hospital with bilateral Rapid Rhinos in place already. Despite this, patient continues to have significant epistaxis. What do you do now? Take Away #1:
Posterior epistaxis should be suspected when the patient has heavy bleeding, especially bleeding that is brisk in the posterior pharynx. Another important sign is if the patient has anterior nasal packing in place and continues to bleed significantly. At this point, the nosebleed is likely posterior.
Take Away #2:
There are 2 types of nasal tamponade devices: one that is designed for anterior nosebleeds and one that is designed for posterior nosebleeds. The Rapid Rhinos we typically stock in our ENT carts are a single balloon anterior packing device. There are also sometimes long Rhino Rockets in the drawer but they also have a single balloon. A single balloon device will not control a posterior nosebleed no matter how long it is.
Posterior nosebleed control requires 2 balloons, one for the posterior vessels and one for the anterior vessels. If a patient arrives as a transfer with nasal tamponade device is in place and there is only one inflation balloon sticking out of the nose you know that this is not an adequate device for controlling a posterior nosebleed and must be exchanged.
Take Away #3:
Posterior packing can be achieved using a commercial device with 2 balloons such as the Epistat, if available. A lot of ERs, including ours, do not regularly stock the 2 balloon devices, and if they do, often no one knows where they are. The alternative device to use is a 12-14 French Foley catheter. A short summary of the procedure is:
Insert a Foley catheter into the nare and advance until you visualize the tip of the Foley catheter in the posterior pharynx.
Inflate the Foley catheter with 6 to 8 mL of air and then applied traction on the end of the catheter until the balloon wedges in the posterior nasal recess.
After the catheter has been adequately seated, inflate up to 20 mL while continuing to apply traction to prevent the balloon from slipping back. You should see mild deformation of the soft palate from the inside of the mouth.
Secure the Foley catheter to the patient’s face with traction and reapply the anterior nasal packing.
This procedure is uncomfortable and there are different schools of thought as to whether or not the patient should be intubated prior to this procedure. If patient is not intubated, adequate pain control and/or sedation are required.
Extra stuff: Neurosurgery should be consulted if embolization is required. Unfortunately there is no great video of foley placement for posterior packing available. This is the best I could find. It is not in English but it is a good demonstration of the procedure. The only difference is the person the video does do the second inflation:
Of note, Dr. Chale located a box of the double-balloon rapid rhinos and we will now have one in each ENT cart. Thanks, Dr. Chale! Here’s an instructional guide to using it. The TL;DR is that the balloon port with the green line on it is the posterior one.
Laura Saltzman, MD is a current third year resident at Stony Brook Emergency Medicine. Resources
Edited by Bassam Zahid, MD