How To Use SALAD To Manage Unstable Epistaxis and the Airway

Standard reviews of epistaxis in the emergency medicine literature center on the epidemiology, etiology, whether the bleeding is anterior or posterior, and methods by which bleeding can be controlled. As with other entities, management of the airway must take precedence. While unusual, nosebleeds may present with life-threatening airway compromise. This is a discussion of a potentially disastrous airway outcome.

A 91-year-old Russian-speaking female on dual-antiplatelet therapy presented to the ED via ambulance with a left-sided nosebleed. She was reported to have had a mechanical fall, landing face forward without loss of consciousness, and has had a continuous nosebleed since then, per EMS and the home care provider.

On EMS arrival, it was noted that the patient had what seemed to be a controllable nosebleed with difficulty locating the source due to constant oozing. She was alert and awake with an intact airway. Due to her sole language being Russian, the initial history was limited. Vital signs on scene included heart rate 90, blood pressure 193/97, and 92 percent oxygen saturation. EMS placed her on non-rebreather at 10 L per minute due to the significant amount of bleeding through the nose, and brought her to the ED. On arrival she remained alert and oriented, sitting upright and face forward with an intact airway. The source of bleeding was identified as venous oozing out of the left naris, and she was spitting blood into an emesis basin. Her Glasgow Coma Scale was 15, and her vitals revealed she was afebrile, had mild tachycardia at 103 beats per minute, bradypnea, BP 189/95 and oxygen saturation varying between 88 and 93 percent on the non-rebreather. A translator was called; however, she was not answering questions appropriately per the translator’s dictation. Per discussion with family over the phone it was determined she had mild dementia, but had been feeling well prior to her mechanical fall. She had no history of anticoagulation, cerebrovascular accident, or myocardial infarction. Review of systems was unable to be obtained due to confusion.

Physical exam of the nasopharynx was difficult due to constant dark venous oozing of blood, with the oropharyngeal exam showing gross blood collections which she could clear on coughing and spitting. After clearing the nasal hemorrhage, an anterior source was ruled out based on lack of clot formation and oozing from a specific source. Posterior epistaxis from Woodruff’s plexus was assumed based on the dark-red consistency of the bleeding. Physical exam of the neck showed no fullness, erythema, or induration. She had a mild decrease in breath sounds to the bases; otherwise lungs were clear. The remainder of the exam was unremarkable.