Page 30 - JSOM Summer 2019

• Floseal is also an option at this stage, but it requires 2. Apply Vaseline to each nostril 2–3× a day.
precise preparation and application (several min- 3. Use a humidifier at night if available.
utes to mix) and is $300–500 per use. Please review 4. No straining, heavy lifting, nose picking. Avoid nose
mixing instructions before opening the box. It can blowing.
be applied by itself (expands over a few minutes) or 5. Keep blood pressure under good control.
around any Merocel or Rapid Rhino and will break 6. Avoid Motrin, Advil, and Aleve until you can discuss
down over 5–7 days. with your regular doctor.
• Other tricks may help—packing the opposite, non- 7. Temporarily hold taking any blood thinners (Couma-
bleeding side can lead to tamponade, but be aware din, Plavix, Eliquis, Xarelto, Pradaxa, Lovenox) until
this may cause respiratory issues for elderly or ill you can discuss with your regular physician.
patients. 8. Avoid picking at your nose with your fingers, Q-tips, or
• As a final resort, can use 14 Fr Foley to provide bal- any other instruments.
loon tamponade/hemostasis from any mixed bleeds
versus true posterior bleeds. Nosebleed Management
• ENT may ultimately need to use a flexible or rigid 1. Sit up straight, hold head slightly forward with mouth
endoscope to ligate/cauterize specific bleeders. open.
• Future therapies may include antibody therapy 2. Hold firm pressure on soft bridge of nose for 15 minutes
directed to bind novel oral anticoagulants (Pradaxa, without letting go. Allow blood to drip out of mouth if
Eliquis, Xarelto), angiography, and IR-based needed, try not to swallow blood as it may upset your
embolization. stomach.
3. If bleeding continues, blow nose and remove any clots.
Disposition Squirt 2 squirts of Afrin in each nostril. Again, hold firm
• Patients can lose significant blood volumes with pressure on soft bridge of nose for 15 minutes without
these bleeds. letting go. Allow blood to drip out of mouth if needed,
• Prior to discharge, repeat vitals and ensure patient try not to swallow blood as it may upset your stomach.
can ambulate and tolerate PO safely without any 4. If bleed continues, then soak a small cotton ball with
symptoms such as pain, nausea, trouble breathing, Afrin until dripping and place in the bleeding nostril.
or dizziness. 5. If you continue to have heavy bleeding (clots), contact
• Strongly recommend observing patient in ED for 2 your physician or go to an emergency department.
hours prior to discharge to help avoid bounce backs. • Any patient discharged needs ENT follow-up within
• Any patient discharged should be advised to hold 3–5 days.
blood thinners for 1–2 days. • If at any point you are concerned for patient’s ability
• Any patient discharged should be given a short course to tolerate packing, there is continual active bleed-
of PO antibiotics (Cephalexin 250mg TID #15). ing, a posterior bleed, or hemodynamic instability,
then place them on observation with CIMS and en-
Nosebleed Prevention sure the ENT is willing to come see the patient within
1. Keep nose moist by using nasal saline spray (Ocean the next 6–12 hours.
Spray), 2 sprays each nostril every hour while awake.

28 | JSOM Volume 19, Edition 2 / Summer 2019