epistaxis

[jpollock]

Received an older lady (80ish) who was transferred to our ER from outlying hospital. She had bilateral mirocels in place with slight ooze around the right side. I pulled the right side, irrigated, and attempted posterior pack unsuccessfully, then gave up and replaced the anterior pack which was 99% effective (still intermittent serosanguinous drips from the packing). I had her tucked away for admission with ENT consulted and the nurse commented that she is now diaphoretic, difficult to arouse, and borderline hypoxic on NRB (she is on NC at nursing home for COPD). Bleeding is still controlled, but how would you work this case up?

[Bjs04f]

so she has bilateral bleeding most likely posterior, is she on blood thinners, and idea of how much she bleed. what do her lungs sounds like has she been aspirating this entire time, whats her monitor (BP, HR etc) have we packed her to the pt of bradycardia and ams?

[jpollock]

bleeding is controlled. No blood thinners but just a baby ASA. H&H is 8.5 (it was 8.4 at outlying hospital). EKG is Afib, trop is negative. Lungs are coarse and diminished throughout, but CXR shows no signs of aspiration. BP is down from 200s -> 150s, HR is down 100->70s, RR is also down 22-> 14. O2 sat on 10L is now also down to 90% with one episode of de-sat to 80s. On repeat exams she is slowly becoming more obtunded.

Anyone have an idea as to what test to order?

[Bjs04f]

Is she normally in afib, was she given any meds at all, other than packing?

[jpollock]

normally Afib, only meds given are saline and 0.5mg Ativan.

well, we got a blood gas and the pO2 was fine...but the pCO2 was >130. She went to the ICU after intubation.

The Ativan was given IV 2-3 hours prior to decline and clinically had no discernable effect on her. My hypothesis is that she already had difficulty moving air due to the COPD and was not far from decompensating at baseline, and by taking away both nostrils we increased the work of moving air just enough to tip her over the edge. The nurse slowly bumped up her O2 throughout the stay to keep O2 sats in the low 90s and in so doing decreased her respiratory drive just enough to not make her feel overly dyspneic.

[Bjs04f]

So iatrogenic type 2 respiratory failure

[tyson]

there is also some known complications w/ anterior and posterior nose packing. usually bradycardia and hypotension, thus just one of the reasons for admission and monitoring. looking at a couple papers, found this, "irritation of nasal laryngeal mucous membrane can cause reflex apnea by swithcing off inspiratory center which causes bradycardia thru sinu-aortic mechanism."

i guess theoretically you could remove the packing and see if helps w/ bradycardia, apnea, but then you're still left with profuse nosebleed which is going to require packing of some sort. And then if it doesn't help and she really has gone over the edge because of decreased respiratory drive, you are in worse position. so sounds like tube, send to ICU was best and most efficient choice.

[Bjs04f]

can always count on tyson to give the answer after the answers been given

[tyson]

That was posing a different theory than what you had mentioned. Please read for content. Pussy.

[Bjs04f]

pollock goes oh she had resp failure from occluding nares. tyson response i bet she had respirator failure from occluding nares, btw arrythmia and hypotension common (what I said). I want to see you to be the first to answer

[tyson]

not factually correct.

he said that the occluding the nares tipped her COPD over the edge, I merely added that this could be reflex mediated rather than progressive decline from occluding nares. two different pathophys explanations. or maybe it was a combo of both.


please see all the September posts. i answered first.

pussy.

xoxoxoxox


tyson

[Bjs04f]

eat a giant bag of dicks my friend, it is on. Next cases posted I will own you.