Epistaxis Pearls from the Internet (Sep.1997)

Title: EPISTAXIS PEARLS FROM THE INTERNET
Date: September 22, 1997
Series Editor: F. B. Quinn, Jr., M.D.

This is a list of "pearls" submitted in response to my request for help in building a CME talk on the subject of epistaxis. List members from all over the world sent words of wisdom in response to this request. Sincerest thanks to all contributors. The lecture went well. The audience clapped, cheered, rose to its feet, carried me around the room singing, and threw me into the hotel swimming pool. (Well, not exactly, but it was fun, and how about some suggestions for another pearl-diving project?)

EPISTAXIS PEARLS FROM THE OTOHNS LISTSERVER - 1997

Date: Mon, 12 May 1997 22:52:51 -0400 (EDT)
From: Michael Rontal, M.D
Subject: Re: epistaxis_pearls

Everyone talks high tech. Here is low tech. We did a survey of "home" nosebleed treatments in the St. Louis ER's in the '60's. Hands down the winner was salt pork. Found in many a low income home back then it really works. I guess we shouldn't use it now- too much salt and too much cholesterol.

Michael Rontal, M.D. Farmington Hills, MI

From: Paul C.Windle-Taylor; Dept.Otolaryngology
Derriford Hospital Plymouth Devon UK.

On this side of the Pond, we suffer too from epistaxis, and I am greatly enjoying and learning much to my benefit from the Great Epistaxis Pearl Debate. OK, guys.....What do you do with the salt pork? Happy packing!

From: Barry Maber, M.D.
Subject: RE: Epistaxis pearls
Date: Tue, 13 May 1997 20:21:38 -0500

I too have caused horror when asking a patient to forcefully blow the clots out of the nostrils, but this is much more efficient than poking around with a suction. Interestingly, I have been impressed that this often of itself seems to stop the trickle of bleeding and not all that infrequently the bleeding site cannot be identified. I still have not found a satisfactory explanation as to why clot removal in this as well as other circumstances of bleeding is often therapeutic, beyond aiding visualization. Depending upon clinical and social circumstance I may admit for observation - some of these don't bleed again. When I was less experienced I used to pack all suspected posterior bleeds even if they were not actively bleeding and a site not determined. This is what we were taught and it seemed to provide some reassurance.

However, over time I became convinced of the futility of this as well as its lack of much 'logic'. Now, if their clinical or social circumstance causes me to be concerned I admit for observation without any packing but strict bed rest, sedation if necessary, and head elevated. I continue this for 48 hours without bleeding and ambulate after 48 hours and then home after another 24 - 48 hours if no bleeding.
I am impressed how many stop under this type of rest regime. I also use endoscopic assessment for some bleeds and have tired various measures to keep the field clear including contralateral suctioning. This is certainly more tedious but can avoid the discomfort and morbidity of packing, particularly in the elderly or compromised patient.

I also like using Gel-Foam with topical thrombin for managing bleeds where there is a bleeding disorder or dyscrasia. Gel-Foam is also useful for children. Easy to insert and doesn't have to be removed. Overall, I have been impressed about how little we really know about the pathogenesis of the "spontaneous posterior bleed" and it seems that most of our pearls are based upon anecdotal experience rather than solid evidence.

Regards to all
Barry Maber

Date: 12 May 97 16:50:13 EDT
From: Robert Slack
Subject: Re: Epistaxis Pearls

I only have 15 years experience in ENT and the last 6 have been as aUK consultant with a lot of 'junior cover', but I think I still have a pearl worth dropping re epistaxis. For those patients whose noses are full of clot, I abandon the suction apparatus, give the patient a 6 ft long piece of 2 ft wide 'Kleenex' tissue, stand 10 ft clear to avoid the blood shower, and to the horror of all relatives and nurses who know better, tell them to blow their nose as hard as they can, thus dislodging the built up clots which are simply getting in the way. This results in an excellent view of what is often a small lesion which can be easily controlled with cocaine ( still easily available here in the UK!) soaked cotton wool and then cauterised.

Rob Slack, Bath UK.

Epistaxis pearls from Dr. Murray Grossan:

Many patients I see after an ENT visit for cauterization are bleeding again because of failure to add an antibiotic. If they are bleeding, there is infection present. I always prescribe an ointment either neosporin or bactroban - both have pointed tips for easy insertion. I don't always cauterize, allowing for the antibiotic to control the bleeding. For hemorrhagic telangiectasia, I have had excellent results with IV premarin, 20 mg. The trick is, when adding diluent, don't shake it, the molecule is very delicate, just swish it. The most important thing in dealing with ER nosebleeds is to dress for the occasion. You aren't going to do good if your are busy ducking the blood flow to save your new suit. Dress in scrubs and you can relax more. ER bleeding always has elevated b.p and anxiety and IV for this is often indicated. Make sure the blood pressure is being controlled. After the nosebleed, on the 1 week visit, continue on antibiotic ointment and saline spray untill membranes are back to normal about 2 weeks. It seems redundant to mention this but I do anesthetise the nose before cauterization.

After an ER bleeder, never be shy about orders re Bed Rest, no telephone, only soft room temperature diet, etc if you don't wan't to return at 2 AM. In older patients with lots of dark spots on skin from bleeding, I like to add Rutin and Vitamin C to help the physiology.
And thank you Dr Quinn for your many contributions.

Murray Grossan, M.D.

Date: Tue, 13 May 1997 08:04:44 +0800
From: Dr. H.S. Sharma
Subject: Re: OTOHNS digest 640

Dear Dr,
At times gelatin sponge placement in the area of bleeding especially when its origin is not localised and in cases of blood dyscrasias is useful method to control the bleeding. I will be thankful to you if you send me all these information about personal experience of epistaxis. This will help me to pass these informations to fellow collegues. Thank you.

Dr. H.S.Sharma, Lecturer, Department of ENT, Hospital USM
Kubang Kerian, MALAYSIA

Date: Mon, 12 May 1997 22:57:07 -0400 (EDT)
From: Tom Stark, M.D.
Subject: Re: Epistaxis Pearls

I remember reading this pearl at least 15 years ago, and I can't recall the source to give him fair credit. I'm sure it came from an old wise sage. It is great for keeping your at home patient out of the ER with a relatively minor bleed.
1) Have the patient spray his/her nose liberally wtih Afrin; 4-5 squirts on both sides.
2) Wait 3-4 minutes then have him blow his nose as hard as possible to get out all the clots.
3) Then in about one minute spray liberally with Afrin again.
Occasionally steps 2 and 3 have to be repeated.
I have found this a reliable way of controlling the 3 a.m. epistaxis...at least it holds them until they come into the office the next day.
Good luck,

Tom Stark, M.D. The Woodlands, TX

Date: Tue, 13 May 1997 00:29:02 -0400 (EDT)
From: Robert Stewart, M.D.
Subject: Re: epistaxis_pearls

In the past few years I have change my treatment for epistaxis. It seems to me that to be truely effective in controlling the problem (and getting a good night's sleep), you have to find the bleeding site.

In my office I will use the microscope for chronic anterior bleeds. I have been amazed at how many small vascular lesions I have found and cauterized (usually electrocautery) successfully. If I can't find a source after a complete endoscopic exam, then I'll try moisturizing measures and have them return if further bleeding occurs.

When called to the ER, I have them start an IV, get the endoscopic sinus surgery equipment, and various cautery devices (usually an insulated suction cautery). I give the patients IV sedation and pain meds (both IV and topical)as needed, clean the clots out, and perform a complete endoscopic examination.

With this technique I am usually able to treat most posterior bleeds without packing or hospitalization. This is great for the patients but I find it has doubled my time when compared to packing the patient and admitting them. If I'm not able to control the posterior bleed endoscopically, I usually have had to perform an IMA ligation despite posterior packing.
Overall I feel the key point is to positively identify the bleeding vessel. Even if you don't cauterize the vessel it will allow you to place your packs with greater confidence.

Robert Stewart, MD, San Luis Obispo, CA

Date: Tue, 13 May 1997 05:55:31 -0600
From: Tim Frost, M.D.
Subject: Re: epistaxis_pearls

OK, here are a couple that may be obvious, but:

1. If you are going to try endoscopic cautery of a posterior bleed, and this seems to work well if you can see what you are doing, the main problem is that the blood fills up the nose so fast you can't see anything with the scope. So to keep the nose clear and see what you are doing place a large (16-18 fr) red rubber catheter in the nasopharynx via the opposite nostril on suction. I usually cut off enough of the tip to just leave the extra side holes in the tip.

2. I always have patients use bacitractin ointment(or vaseline, but it smells more) copiously (like 10-12 times per day, if needed to keep the nostril COVERED with it at all times) after and sometimes instead of cautery. I can't tell you how many times patients have been using saline spray and it just doesn't work, or they have been using ointment "Twice a Day" which is not enough. I tell them, "if the nose isn't continously and completely greasy, you're not using it often enough".

3. A 50/50 mix of Afrin and Pontocaine seems to be as effective as Cocaine(and there have been several studies confirming this) and is much cheaper and safer.

Keep up the great work, Dr. Quinn and thanks for starting this useful discussion topic. I will look forward to the finished transcript.
Tim

Tim Frost, M.D.
Alamogordo Ear, Nose and Throat - Facial Plastic Surgery
1401 10th St., Suite C, Alamogordo, NM
(505)437-4533, Fax:(505)437-5009

from: Michael Rontal, M.D.
subject: Re: epistaxis_pearls

A 25 pearls for epistaxis control, in no particular order, just as they came to mind:

1. Learned from Frank Ritter at U of Michigan- layer in iodoform and bacitracin gauze, starting at the floor of the nose. One layer at a time until can't go higher.

2. Many post bleeds are really from the inferior meatus. Decongest the nose and pack the inferior meatus, layer by layer with the iodoform and bacitracin gauze.

3. Never seen a primary anterior ethmoid bleed from the middle meatus, always from the roof of the nose where the vessel crosses

4. Never seen a posterior ethmoid bleed and only one true posterior septal bleed to cause bilateral bleeding. If it continues to bleed, it is from the same side and not controlled.

5. Balloons can cause anterior or posterior stenosis, beware

6. Remember the pull out strings for a gauze posterior pack. Make everyone aware why there is suture material hanging from the mouth with this type of pack. Make anyone who cuts the strings apologize to the patient for the pull out procedure.

7. Never pull a pack at night or Friday night unless you are on call and have no other plans for of your own

8. The elderly don't do well with posterior packs. Oxygen desat, restlessness and disorientation. A whole different set of problems for these patients

9. Antibiotics on packs and orals too. Bactroban works well but doesn't make the removal any easier like the petrolatum antibiotics do.

10.For some reason, antihistamines help prevent rebleeds. Thank you Jack Anon

11. Cautery does not work if there are no platlets or other clotting factors- leukemia, aplastic anemia, cirrosis, ITP,

12. Think conservative with Osler Weber Rendu. One lesion at a time. And also, OWR bleeds from everywhere. These unfortunate folks die from GI bleeding and complications of transfusion, rarely from epistaxis alone.

13. On the dying note- patients do die from epistaxis. They are a mess from the bleeding up front but they die from the bleeding posterior. Check them often in the hospital. A good pack anterior and the nurses never check the pharynx because they look so clean and comfortable. I saw a young man die this way.

14. The radiologic coils do work but there is a risk here too. Ischemic pain, rebleed and avascular necrosis of the maxilla have all been seen here.

15. Too much cautery, especially from both sides, leads to perforation. Even with silver nitrate.

16. Septoplasty never stopped a bleed for me but it did allow easier packing.

17. Chronic ethmoid disease can be a sourse of bleeding. Endoscopic ethmoid surgery (FESS) has worked when the sourse is seen from the middle meatus.

18. I like the endonasal endoscopic electrocautery (EEE, I like that acronym). Neat to see the vessel squirting and then turn off.

19. For IMA ligation- strip the mucosa of the max sinus and then electrocoagulate the bare bone in the inferior posterior maxillary sinus. This causes an avascular area on the posterior side of the maxilla and makes finding the IMA just that much easier. Have confidence that the IMA ligation worked and do not repack.

20. We used to inject glycerin into the pterygopalatine fissure through the greater palatine foramen until someone reported wide spread vascular spasm and blindness. But lidocaine and epi does help gain some control for a while

21.The anterior ethmoid foramen and artery is found in the fronto-ethmoid suture, 25 mm back from the easily identified anterior lip of the lacrimal fossa when performing an AEA ligation.

22. The posterior ethmoid artery is 11 mm back from the AE foramen, is absent in 25% of cases and is only 7 mm from the anterior lip of the optic canal

23. You know those pesky bleeds from the crust lifting where you cauterized? Place a bacitracin coated cotton in the vestibule to prevent breathing and drying of the septum. Wear it for several days. The moist mucosa will finally heal over.

24. That blow the clots out plan really works

25. A neat way to pack a nose is to place two fingers of a glove coated with antibiotic ointment and still attached to each other, one into each nostril. Pack into the cavity of the fingers with iodoform. When you unpack, pull out the packing and then the latex glove. It won't tear the mucosa this way. Learned from my brother when he was at Minn.

Michael Rontal, M.D.

Date: Sat, 17 May 1997 12:06:12 -0500 (CDT)
From: Roy S. Goodman, M.D.
Subject: still more epistaxis pearls

I find that it is usually easier for me, and more comfortable for the patient, if I hydrate a merocel pack before inserting it rather than trying to insert it dry. Grasp the pack with a bayonet forceps and it goes in fine.
Especially in patients with bleeding problems, I cover the bleeding area of the septum with a sheet of Surgicel before putting in the pack. Surgicel has hemostatic properties, and I like to think that it protects the mucosa when you slide the pack out.

My best epistaxis pearl is now (fortunately) obsolete. Back in the pre-merocel era, I found that 1 inch by 36 inch vaseline gauze went in and came out twice as fast and half as uncomfortably as 1/2 inch by 72 inch. When patients complain about the merocel packs, I point out to them that twenty years ago I would have put a couple of yards of vaseline gauze up each nostril.
Speaking of epistaxis, is there a consensus on how long a posterior pack should remain in place?

Roy S. Goodman, M.D.

Date: Wed, 14 May 1997 11:21:40 -0500 (CDT)
From: Yves Jankovski, M.D.
Subject: Epsitaxis Pearls

Robert Stewart, MD wrote :

"It seems to me that to be truely effective in controlling the problem (and getting a good night's sleep), you have to find the bleeding site."

I agree completely. Note we talk about ENT's epistaxis, the 10% GP cannot manage, the 1% of all. In my experience, anytimes you do not find the spring w/ carefull endoscopic exam (you know, the one that's bleeding once you have turn you back), it is a high risk epistaxis. I had 3 cases that had been all over only with maxillary embolisation, even 1 case having not seen the leak with the Xrays. The main problem is management of a bleeding or of a not bleeding nose. For a good night sleep and a carefull exam next morning, Epistaxis balloon is a good device, I've used a lot of them without problems. Local surface anesthesia for electrocautery is impracticable w/ bleeding. 1cc sub-mucosal lidocaine/adrenalin is necessary (and sometimes stop the flood).
I agree w/ use of bipolar if possible.
I agree w/ use of microscope.
I agree w/ use of suction in opposite nostril to clean the field.

Glad to see we share the same experience and are not so different. Great idea Dr Quinn.

Yves Jankovski, M.D.
Bergerac, France.

Date: Fri, 16 May 1997 08:56:55 -0500 (CDT)
From: Jim Hutchinson, M.D.
Subject: Re: Epistaxis Pearls

This has been a most interesting discussion and I have no Rx pearls that have not been submitted, but do have a few thoughts about the subject.

1. Salt pork, said to be the best Rx, is not a routine pharmacy item and 2 am dietary service is spotty at best.

2. Trichloracetic acid used vigorously may result in septal perforation and the same may be said of cauterization, especially should there be bilateral bleeding requiring its use.

3. Bleeding sites can be unusual and easily overlooked. I recall one from the middle third of a middle turbinate, arterial bleeding at the mucocutaneous junction of the septum and a "Kesselbacks" bleed that turned out to be ant. septal art. that put the patient in shock.

JRB(Jim)Hutchinson, MD
2197 Kodiak Dr., Atlanta, GA 30345-4172

Date: Mon, 12 May 1997 11:07:16 -0700
From: Don Setliff
Subject: Epistaxis

I have enjoyed your grand round topics on this service and offer the following regarding epistaxis:
What I have learned, mostly after residency through patient contact, is that posterior packs are seldom necessary. I feel sure that this is partly due to patient selection, since there are more patients with blood dyscrasias in university centers. I have packed one nose in the past 10 years, that in a pregnant woman who failed to respond to any conservative measures.

Oxymetazoline spray stops more than 90% of nosebleeds, including posterior bleeds, if it is used properly. All clots must be evacuated, the side of the bleeding then vigorously sprayed several times. I have not seen (at least not recognized) any complication or dosage limit, even in hypertensive or elderly patients. If the bleeding continues, the procedure is repeated in 3-4 minutes, and again 3-4 minutes later if necessary.

While it is ridiculously simple and remarkably effective and safe, it is almost never done by emergency room doctors and/or general practitioners. I think most members of our specialty are onto this method, but have seen some colleagues go to packs sooner than I would, especially in elderly folks with vascular disease.

The other obvious things that GP's overlook is to eliminate the predisposing factors, which include intake of aspirin, NSAID's, decongestants, and tranquilizers. Of course the patient should be questioned about their home and work environment, as to the level of heat and humidity. Older people often like a warm environment and need to be told to turn down their thermostats or room heaters. They can wear sweaters or other additional clothing to stay warm.

These measures, along with education as to where to apply pressure when bleeding occurs, anterior lubrication with KY jelley, and keeping the head elevated when possible, all help to get the patient through this problem without nasal packing.

I hope these "pearls" will be helpful. I feel sure you have probably heard them all before. Thanks again for your service to the ENT community.

From: Dr Harris D. Levin
Subject: Nasal Septal Perforation

On those patients in whom surgical repair of NSP is not possible or has failed, I have taken 0.03 inches thickness sialastic sheeting and sandwiched the perforation with the sheeting about 5-8 mm past the perforation edges and sewn them in with continous multiple horizontal mattress sutures with 4-0 proline (not nylon- it's not long lasting under these circumstances). It's much easier to keep clean long term than a rough edged perforation and stops bleeding permanently on the spot. I also use it on those epistaxis patients where nothing has halted the bleeding longterm who recurrently bleed off the anterior nasal septum (there are a few of those patients around).

Harris D. Levin MD, Davis CA

Date: Mon, 12 May 1997 07:05:49 -0500 (CDT)
From: F.B.Quinn
Subject: epistaxis_pearls

I've been treating nosebleeds as an otolaryngolgist for forty two years, which would give me reason to claim to be "experienced" that is, unless, you realize that it may just represent one year's experience repeated forty-two times. Remember, these are just my own opinions-

1. When you can't find an Epistat, a 30 cc (or 5 cc) Foley and a package of 1" vaseline gauze, all secured with a padded umbilical clamp, will do and these items are to be found in almost any hospital. Be sure to fill the balloon with water(saline?) rather than air, since air leaks out faster thru the pores in the rubber. Sure, the petroleum jelly will rot the rubber, but by then the nosebleed will probably have stopped.

2. The ubiquitous silver nitrate sticks are widely used (by my residents) to cauterize the bleeding point. This is because

a. the AGNO3 sticks are in every treatment cabinet
b. silver nitrate is relatively non-toxic
c. my residents don't know any better, and won't listen to me (!)

The preferred chemical cautery is a saturated solution (that's right, 100%) of trichloroacetic acid; lighly moisten a tightly wrapped tiny bit of cotton mounted on a steel or brass cotton carrier with TCA and apply it directly to the bleeding point and hold it there. The TCA has an immediate and vigorous vasoconstrictive effect, and penetrates much deeper and more quickly than the silver nitrate dissolved in blood. 'S matter of fact, IMHO silver nitrate is only good for making white streaks down the back of the throat, and black stains on the upper lip. Time was when a favorite medical fraternity party trick was to wait 'till someone passed out and then take a silver nitrate stick, dip it in his drink, then print an obscene word on his forehead. He'd wear a scrub cap to class for the next three weeks.

Francis B. Quinn, Jr., M.S.(ICS), M.D.
University of Texas Medical Branch, Galveston, TX

"War talk by men who have been to the war is likely to be interesting, while moon talk by a poet who has never been to the moon is likely to be dull." -- Mark Twain

Date: Tue, 13 May 1997 18:51:05 -0500 (CDT)
From: Shigeru Ishikawa, M.D.
Subject: Re:epistaxis_pearls

Exception on the case of hemorragic tendency, I always use the bipolar cauterization.I had the experiences in my residency that the pin-point bipol- ar cauterization for the bleeding point often made worth re-bleeding. From then, I use the bipolar cauterizing forceps with the tips open (3-4mm) after removing the blood clots and doing anesthesia. I don't cauterize the bleeding vessel itself but the bleeding area (containing feeding vessels surrounding the bleeding point) with low power. Although the cauterized area is wider than the pin-point cauterization and the mucosal recovery is prolonged, the hemostat effect will be successful.

Shigeru Ishikawa MD. PhD.
Dep. Otolaryngology, Kanazawa Municipal Hospital, Kanazawa, Japan
Patulous Eustachian Tube Home Page [http://jun.ient.or.jp/~ishikawa/]
Nasal Endoscope HP [http://www.ient.or.jp/nes/]
Vital Image of Parasinuses [http://www.ient.or.jp/para3D/]

Date: Fri, 16 May 1997 02:57:12 -0500 (CDT)
From: Viveka Westergren, M.D.
Subject: Re: epistaxis_pearls

Still being junior ENT specialist and take care nose bleeds coming in day and night time I refer the way we usually handle 'the ordinary'.

1. Identify the the damaged vessel. If not possible due to bleeding do 2. anyway.

2. Put a piece of cotton moistured with xylometazolin (constrict the vessels) and xylocain in contact to site of bleeding. Let the patient rest head high 10 minutes.

3. Burn chemical with chrome acid pearl - do not stop to early.

4. Put new cotton this time with paraffine in the nose. Instruct the patient to remove by himself after 24 h.

Greetings.
Viveka Westergren, MD
Dept ENT Head & Neck Surgery Karolinska Hospita, S- 171 76 Stockholm, SWEDEN

Date: Thu, 15 May 1997 12:22:16 -0500 (CDT)
From: Sheri L. Rolf, M.D.
Subject: Re: Epistaxis

These epistaxis pearls are great. Truly, epistaxis is a problem of which no one is fond.
In addition to having the patient blow out the clots, I've found hydrogen peroxide to be an extremely useful adjunct in clearing out the nose, and actually even stopping some of the smaller bleeding sites. In my experience, by the time a patient has been worked over by a couple a ER visits, there are usually multiple mucosal bleeding points, in addition to the actual original bleeder. If the mucosa is diffusely bleeding, I'll have the patient blow the nose initially. then use H2O2 in a bulb syringe and irrigate out the bleeding side. You've got to be ready with suction, because the bubbles are impressive.
Frequently, you need to do this a couple of times, but this will usually stop the lesser sites from bleeding as well as dislodge clots which may be masking the bleeder. From here on, it's topical anesthesia with 4% cocaine, if available, analgesia/sedation (I prefer demerol, because, if it doesn't make the patient vomit, it seems to create some peripheral mucosal vasoconstriction) followed with xylocaine/epi infiltration, and cauterization, if possible. Otherwise, merocel and prayer.

I would be interested in what types of units/equipment that folks use in their offices for epistaxis cauterization. The standard suction cauteries are frequently too large, while the old reusable suction cauteries have inadequate suction and plug up frequently.

Ciao,
Sheri L. Rolf, M.D.
Billings, MT

Date: Wed, 14 May 1997 05:27:49 -0500 (CDT)
From: Stephen A. Smith, M.D.
Subject: epistaxis pearls

I am able to control most "posterior" epistaxis with long (almost square cross section, not "flat") Merocel strips about 3-3.5" long. I sometimes place 2 or three in the nose (bleeding first controlled with topical vasoconstrictor spray and 1.5-2.0 cc of lidocaine/epinephrine into the pterygomaxillary space via the greater palatine foramen if needed). The nose is anesthetised with topical anethetic and the injection, if used, helps.

The "trick" is to place the strips strategically before expanding and to get them all the way to the nasopharyngeal wall. The inferiormost is place first and the superiormost, last. The superior is expanded first, any medial one, second, and the one assumed to be against the bleeding site, last. Before placement, each is heavily coated with Bacitracin ointment both for lubrication and to "waterproof" the material so it doesn't expand when in contact with the nasal mucus or blood. When all intended strips are in place, expansion is triggered by the injection of cortisporin otic suspension through a 25 guage needle into the anterior aspect of each strip.

The combination of the Bacitracin on the outside and the Cortisporin on the inside allows for lubrication, placement, and reduced foul odor at removal 4-5 days later (outpatient). Oral antibiotics are used with all packing. I find this better than encasement of Merocel in rubber "fingers," which I did years ago and it is tolerated quite well.

Date: Wed, 14 May 1997 17:30:01 -0500 (CDT)
From: Philip Scott, M.D.
Subject: Re: Epistaxis pearls

Ever tried to cauterize a vessel and it keeps on hosing from the middle of a black blob caused by the silver nitrate? I use cotton on orange stick to apply local pressure for a few minutes as the bleeding point is invariably too far inside the nose for nasal pinch to help. I keep it in place for about a minute or until my arm and hand get sore, which ever happens first. Amazing the way the 'simple' things cause so much response!

Philip SCOTT, M.D.

Date: Wed, 14 May 1997 23:32:06 -0500 (CDT)
From: Dr. Andrew W. Moyce
Subject: Epistaxis Tip.

Pretty simple, but for a capillary bleeder in the anterior septum; After topical anesthesia, I place a piece of DRY cotton over the bleeder. Then I use the back of the Silver Nitrate stick to push the cotton back into the nostril until the bleeder is visible. The dry cotton aborbs the blood as you identify the exact site and then protects the surrounding nasal mucosa from the silver nitrate. I find that the silver nitrate stick works okay if you hold it there long enough ... at least a minute.

Since Cocaine has become so hard to use in the office, we buy 5% Lidocaine ointment from the dental supply companies and find that it is a fast acting and effective topical anesthetic for nasal procedures such as this.
I'm sure that everyone knows by now that for posterior bleeds the Xomed Post Pak balloon designed by Richard Goode is a life saver . . . I keep one in the glove compartment of my car in case the ER is out of them.

Andy Moyce in Oakland, CA

Date: Wed, 14 May 1997 12:29:11 -0500 (CDT)
From: Dick Stasney, M,D.

Vis a vis epistaxis, I read an article in the Archives written in the early 70's from the Brookland V.A. Hospital discussing the use of Amicar (aminocaproic acid) sprayed into the nose for epistaxis in people with bleeding diatheses.
I have tried it on several occasions over the years and it does seem to be effective in these most difficult patients (hemophilia, decreased platelets, etc.). You get an Afrin bottle, pour out the Afrin and fill it with a vial of Amicar. Then the patient blows out all the clots and sprays the Amicar qid prn. Theoretically, it stabilizes the clot.

Dick Stasney, M.D. -- Houston, Texas