Take Home Points:

Posterior epistaxis is a rare, life-threatning presentation.
The key is in identifying and rapidly gaining control with a posterior pack or foley catheter.
These patients often require surgical intervention so get ENT to the bedside and admit to a place with a higher level of monitoring.

REBEL Core Cast 123.0 – Posterior Epistaxis

Recognition

Typically will have heavy bleeding both anteriorly and posterior into the oropharynx. These patients have a tough time because they’re continually trying to spit out or swallow blood
Tachycardia is common and hypotension while not common isn’t unexpected. Very different from anterior epistaxis where VS usually unremarkable or maybe a bit of hypertension
Failure of anterior pressure or packing to stop bleeding: apply pressure but still see brisk posterior bleeding or even place b/l pack and see continued posterior bleeding

Start with the basics

IV, Supp O2, Monitor
Consider blood products if the patient appears to be losing a lot of blood or they report heavy blood loss. VS abnormalities can drive this as well
Strongly consider reversal of AC (this will typically come after control)

Stopping the Bleeding

PPE: these things bleed like stink. Anecdote. Gown, gloves and most importantly eye and face protection
Ideal: commercial posterior pack
- Two balloons – one for anterior, one for posterior
- Place the device (straight back parallel to the floor)
- Inflate anterior balloon (10-15 cc) of air
- If still bleeding, inflate posterior balloon (5-10 cc of air)
Foley: if no commercial device
- Place foley catheter just as you would place a nasal tampon
- When you see the tip of the foley in the posterior pharynx, inflate balloon (5-10 cc)
- Need to pull back a bit and secure (can do this with tape on the nose)

Post Placement Care

Antibiotics: standard practice to give cephalexin or amox/clav. Literature doesn’t defend this approach but, the lit is pretty sparse. The idea behind abx is to prevent things like AOM and TSS but neither should be much of an issue with short term placement
ICU Admission?
- Traditional teaching is that these patients are at risk for life-threatening bradydysrhythmias and should go to the ICU
- Literature here is non-existent. Two oft-cited articles
  - Cassisi Laryngoscope 1971 – no mention of cardiac events in the article but widely cited
  - Zeyyan Laryngoscope 2010 – slightly lower HR in the packing group but no bradydysrhythmias
- Before throwing ICU out
  - Hypoxia can occur – Cassisi found about a 20 mm Hg drop in PaO2 but all the patients in this publication were sedated so the packing may not have been the issue
  - look at Viducich 1995 Acad Emerg Med – showed that 18% of the 88 patients with posterior epistaxis required a surgical intervention. With that in mind, you want to consider placing patients into a setting where they can be frequently reassessed – perhaps SDU. This will be pretty location specific. If you treat a posterior bleed at a hospital without ENT, I would transfer as surgical intervention is pretty common

References

Cassisi NJ et al. Changes in arterial oxygen tension and pulmonary mechanics with the use of posterior packing in epistaxis: a preliminary report. Laryngoscope 1971; 81(8): 1261-6. PMID: 5569677
Zeyyan E et al. The effects on cardiac function and arterial blood gas of totally occluding nasal packs and nasal packs with airway. Laryngoscope 2010; 120: 2325-2330. PMID: 20938948
Loftus BC et al. Epistaxis, medical history and the nasopulmonary reflex: what is clinically relevant. Otolaryngol Head Neck Surg 1994; 110: 363-9. PMID: 8170679
Viducich RA et al. Posterior epistaxis: clinical features and acute complications. Acad Emerg Med 1995; 25(5): 592-6. PMID: 7741333
Corrales CE, Goode RL. Should patients with posterior nasal packing require ICU admission. Laryngoscope 2013; 123: 2928-9. PMID: 24114977

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)

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