AI Summary
5 min readA 3 AM case opens the episode: an 80-year-old man on apixaban for atrial fibrillation arrives pale, diaphoretic, hypoxic to 84%, and actively spitting blood. He is leaning forward, gurgling, with bright red blood soaking through fresh pads from both nostrils. The paramedics report a sudden bilateral nosebleed that did not respond to pressure or ice at home. The patient is now coughing up clots, vomiting blood, and short of breath. This is the kind of epistaxis that kills not by exsanguination but by airway contamination and aspiration. The episode’s guest experts—emergency physician Leor Sussman and his brother Daron Sussman, an otolaryngologist at McMaster University—walk through a stepwise approach to managing epistaxis, from the simplest pressure maneuver to the most advanced airway rescue.
Anatomy, risk factors, and the dangerous presentations
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What you'll learn
- 1 (00:33) **Case Presentation: The Sick Epistaxis Patient** - An 80-year-old on apixaban presents with a massive, bilateral nosebleed, hypoxic, hypotensive, and actively vomiting blood.
- 2 (07:44) **Anchoring in Anatomy: Anterior vs. Posterior Bleeds** - Understanding the blood supply (Little's area vs. sphenopalatine artery) is key to knowing where to look and how to intervene.
- 3 (10:51) **Risk Factors for Bad or Recurrent Bleeds** - Anticoagulation is the biggest risk, but other factors like nasal oxygen, CPAP, and certain supplements are key to identify.
- 4 (15:42) **Red Flags on Clinical Assessment** - The most critical decisions are made before picking up a speculum; look for airway contamination and signs of shock.
- 5 (19:08) **Patient Positioning and the Art of Pinching** - Leaning forward is safer and more effective than leaning back, and the key to pinching is sustained, hard pressure on the right spot.
- 6 (27:10) **Airway Management in the Bleeding Patient** - This is a predicted difficult airway due to poor visualization; prepare for RSI and have a plan for a blind technique.
- 7 (33:36) **ENT Airway Pearls: Irrigation, Suction, and Clot Removal** - A surgeon's tips for improving visualization during a difficult intubation in a bleeding patient.
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Show Notes
Epistaxis is usually straightforward—until it isn’t. How can you distinguish an anterior bleed from a dangerous posterior bleed? What’s the best sequence for compression, vasoconstrictors, TXA, cautery and packing? When should you reach for an anterior balloon tampon or posterior dual balloon? And how do you manage the airway when torrential bleeding fills the oropharynx? In this Epistaxis Management Deep Dive, Anton is joined by emergency physician Dr. Leeor Sommer and otolaryngologist Dr. Doron Sommer for a practical step-wise approach to everything from the routine nosebleed to life-threatening hemorrhage... If you find EM Cases useful in your practice, please consider making a donation to help us keep producing free, open-access emergency medicine education here: https://emergencymedicinecases.com/donation/
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