Prehospital Academy Lesson 22.2
HEENT: Epistaxis and Post-surgical Oropharyngeal Hemorrhage
This lesson covers the assessment and management of epistaxis (nosebleeds) and post-surgical oropharyngeal hemorrhage, common emergencies affecting the HEENT region. While often self-limiting, these conditions can be distressing for patients and, in some cases, lead to significant blood loss or airway compromise, requiring prompt and effective EMS intervention.
Epistaxis (Nosebleeds)
Epistaxis is a common occurrence, often benign, but can occasionally be severe. Understanding its causes and appropriate prehospital management is crucial.
Causes of Epistaxis:
Local Trauma: Digital trauma (nose picking), foreign bodies, facial trauma.
Environmental Factors: Dry air, changes in altitude.
Medical Conditions: Hypertension (high blood pressure), coagulopathies (bleeding disorders), certain medications (e.g., anticoagulants).
Inflammation: Rhinitis, sinusitis.
Types of Epistaxis:
Anterior Nosebleeds: Most common (90-95%). Originate from Kiesselbach's plexus on the anterior nasal septum. Typically less severe and easier to control.
Posterior Nosebleeds: Less common (5-10%) but often more severe, involving larger vessels deeper in the nasal cavity (e.g., Woodruff's plexus). Blood may drain posteriorly into the throat, increasing the risk of aspiration.
Prehospital Management of Epistaxis:
Patient Positioning: Have the patient sit upright, leaning slightly forward. This helps prevent blood from draining into the oropharynx, reducing nausea, vomiting, and potential aspiration.
Direct Pressure: Instruct the patient to firmly pinch the soft cartilaginous part of the nose (just below the bony bridge) for at least 10-15 minutes without releasing pressure to check. Encourage mouth breathing.
Cold Compress: Apply a cold compress or ice pack to the bridge of the nose and/or the nape of the neck; this can promote vasoconstriction.
Maintain Airway: If the patient is unconscious or has a posterior bleed, be vigilant for airway compromise due to blood in the posterior pharynx. Position the patient on their side if necessary (recovery position).
Vital Signs and Shock Assessment: Monitor vital signs, especially in cases of significant blood loss or prolonged bleeding. Treat for signs of shock if present.
Transport: Transport to a medical facility if bleeding is prolonged, heavy, recurrent, or if the patient is on anticoagulants or has underlying bleeding disorders.
Post-surgical Oropharyngeal Hemorrhage
Hemorrhage following surgery in the oral cavity or pharynx (e.g., tonsillectomy, dental surgery) can be a serious complication due to the rich vascular supply of the area and the proximity to the airway.
Causes:
Dislodgement of a clot from the surgical site.
Damage to blood vessels during surgery.
Underlying bleeding disorders.
Prehospital Management:
Airway Management: This is paramount. Blood in the oropharynx can obstruct the airway. Have suction readily available and be prepared for advanced airway techniques if needed. Position the patient to facilitate drainage of blood away from the airway (e.g., recovery position if unconscious).
Direct Pressure: If the source of bleeding is visible and accessible, direct pressure may be applied with gauze.
Vital Signs and Shock Assessment: Monitor for signs of significant blood loss and shock.
Rapid Transport: Immediate transport to a facility with surgical capabilities is essential.
Critical Thinking Questions
A 60-year-old male with a history of hypertension and taking blood thinners presents with a persistent nosebleed. What are the key considerations for your assessment and management?
You are managing a patient with a significant posterior nosebleed. What is your primary concern regarding airway management, and how would you position the patient to mitigate this risk?
A child presents with a nosebleed after digital trauma. What is the most effective immediate intervention you can instruct the parent to perform?
Why is it important to advise a patient with epistaxis not to lean their head back?
In a case of post-tonsillectomy hemorrhage, what are the immediate life threats, and what prehospital interventions can an EMT perform to stabilize the patient before definitive medical care?