Due to the amount of blood loss by epistaxis complicated by anticoagulation for his recent pulmonary embolism, the patient was admitted to the hospital for observation. Reversal of the anticoagulation was considered by the admitting service, but because the patient was only oozing blood, this intervention was not undertaken. Instead, he was continued on warfarin, was treated with an oral antibiotic, and was continued on his inhaled medications for his COPD. He also used his noninvasive PAP device to sleep.
The next day, the patient began to bleed freely from his right nares. The bleeding was initially controlled with compression and positioning and resolved without additional intervention. An otolaryngologist performed silver nitrate cauterization of Kiesselbach’s plexus. The patient experienced no further bleeding, and his hemoglobin remained stable.
The next day, his nose began to bleed briskly. He passed large clots from his nose and mouth. The patient was alert and oriented. He remained hemodynamically stable. His INR was 2.1. Nasal packing was proposed, and the procedure, including the risks and benefits, were explained to the patient.
After obtaining consent from thepatient, the nasal mucosa was prepared with topical 2% lidocaine and 1% phenylephrine. Anterior and posterior nasal packing was successfully achieved with paraffin gauze. This procedure was completed in a monitored environment by an experienced otolaryngologist. However, the patient became agitated 15 to 20 minutes after the nasal packing had been accomplished. He rapidly became apneic, bradycardic, and hypotensive. His oxygen saturation on room air as measured by pulse oximetry decreased precipitously to 50%. These developments were quickly followed by asystole.
Advanced cardiac life support measures were initiated. His airway was secured by oral endotracheal intubation, and oxygen was delivered at 100% fraction of inspired oxygen by bag ventilation. At intubation, only a few small clots were present in the posterior pharynx. No blood was suctioned from the endotracheal tube; therefore, active bleeding was not suspected. The nasal packing remained in place and was not removed. The patient failed to regain spontaneous circulation and died. An arterial blood gas analysis obtained during cardiopulmonary resuscitation demonstrated no methemoglobin on co-oximetry.
Discussion
Because of the high prevalence of epistaxis in the general population, many health care providers (HCPs) are confronted with this problem. Epistaxis in most patients remits without consequence. However, HCPs may be required to intervene. Treatment modalities include simple compression and positioning maneuvers, the application of topical medications, anterior and posterior nasal packing, chemical cauterization, endoscopic electric cauterization, embolization therapy, and surgical arterial ligation. 7 The choice of therapy depends on several factors, including the site of the bleeding, the severity of the bleeding, the availability of resources, and the expertise of the HCP. A localized cause of epistaxis is discovered in only 15% of patients, making a conservative therapeutic approach an attractive initial intervention. 8
Nasal packing is a successful intervention in 70% of patients with posterior epistaxis. In addition, nasal packing is the preferred method for hemostasis in anterior epistaxis when cauterization fails. 3,9 This patient failed simple compression and positioning maneuvers as well as chemical cauterization. For this reason, nasal packing was proposed as a therapeutic intervention. He was hemodynamically stable when the nasal packing procedure was initiated.