Massive epistaxis is considered a medical emergency that requires immediate attention. Symptoms of massive epistaxis include sudden and heavy bleeding from the nose, difficulty breathing, dizziness, and a rapid heartbeat. If left untreated, it can lead to significant blood loss, shock, airway obstruction, and even death. We report a case of a 50-year-old man with end stage renal disease with massive nasal bleeding from the left nostril, shortness of breath, and confusion.
Initial Management
After a rapid assessment, we inserted an anterior nasal pack, soaked in epinephrine, TXA, and an antibiotic-based lubricant. However, the bleeding continued from his nares and posterior oropharynx. We thus removed the anterior packing and instead inserted a Foley catheter into the posterior nasal space and inflated the balloon. Unfortunately, the bleeding still continued. Because he presumably had uremia-induced thrombasthenia (weak platelets), he received blood transfusions and IV TXA. And still -- he continued bleeding heavily.
Trick of the Trade: Dual Catheter Technique
To provide optimal surface area coverage and tamponade effect of the posterior vessels, concurrent anterior packing is usually needed [1]. You can use commercial devices that have a dual balloon setup, but we did not have that available.
Illustration by Dr. Abdelhameed with patient-consented photo of dual balloon technique
Technique
Insert the a 14-French Foley catheter into the nares with the patient's mouth open (balloon 1). Stop when you see the tip of the catheter dangling in the posterior oropharynx.
Inflate the balloon partially with 15-20 cc of air.
Gently pull the catheter anteriorly until you feel resistance such that the balloon is snuggly positioned.
If the bleeding still continues, insert a second Foley catheter until you meet resistance (balloon 2). Inflate this second balloon with 15 cc of air.
For our case, this dual catheter compression technique succeeded in halting the bleed.
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