I had a patient that came in that had a trans-sphenoidal resection of a pituitary tumor. That means they punch through the bone above your top teethe to reach the pituitary gland that sits under your brain. Ouch!
She had recovered uneventfully and was at home recuperating when she developed a massive nose bleed.
I have seen some pretty bad nose bleeds but this was truly horrifying, she sat hunched over a basin with a steady stream on blood from both nares, spitting and coughing out blood and clots.
In addition to her obvious problem there was a big concern over her airway but if we laid her back to intubate she would aspirate blood. And a nasal intubation was obviously out of the question.
we have little devices that look like a Foley catheter that has balloons that you fill with water. It was very difficult to insert them properly with all the blood, the doc - normally very laid back - was tense. He finally got them inserted and inflated but she continued to bleed around them. Another nurse and I started 2 large bore IV's and drew blood for blood count, clotting factors and type and cross-match. Approximately 500cc of blood was in the basin.
Blood continued to flow around the nasal balloons. ENT doc arrived and removed them and packed each side of her nose with about 50 yards of Vaseline gauze packing. It looked horribly uncomfortable. The patients pulse had risen to the 140's despite fluid boluses so we hung uncross-matched blood on the rapid infuser - between the suction and the basin she had lost almost a liter of blood.
The packing didn't work either. Now the ENT attending had arrived. He removed the packing and inserted a Foley catheter into each nare. The balloons were inflated and the Foley's pulled tight and clamped outside the nose with hemostat to provide tamponade in the posterior pharynx then each nare was packed with more Vaseline gauze than you would ever imagine could fit inside one persons head. But, it worked! The bleeding finally stopped and the patient was transferred to the ICU for further monitoring and blood transfusions.
When we measured she had lost 2100 cc of blood!
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9 comments:
I have had several horrible nosebleeds like that myself and they can be as horrible as a difficult airway. Once those foleys are in they need to be monitored for cardiac arrhythmias as well. Thank God they got things under control.
How horrible for her. I hope they were able to fix her.
Now that sounds like a good reason to visit the ER.
Hope she recovers soon.
From foleys in the nose and on tonsilar bleeds to Sengstaken-Blakemore tubes for esophageal varices, balloons seem to be the way to control bleeding affecting the airway, at least as long as you can maintain an airway.
Was there any possibility of injecting epi into the site of the bleed to cut down on blood flow? Or cold water lavage?
I hate nose bleeds...
Donnathedead said: My dad gets nosebleeds like that every so often, they go on for hours, and he loses ALOT of blood. They usually pack him with cotton soaked in cocaine, and then the vaseline gauze; once they left it in there for several, either 4 or 5 days. Poor guy, it was hideous. The problem is that they can't find where he is bleeding from. They've never monitered his heart at all though.
Once I was in the er with him for so long that I wrote the song, "I'm sitting in the ER with a clamp on my nose and I can't feel my toes blues". They published it in the hospital newspaper.
It typical ER, your last two post.
1)Idiot with a toe injury
2)Real friggin' emergency
Strong work, ERNursey.
Strong work indeed!
Wow and I thought my nosebleeds are bad..........poor lady!
how do u deal w/one that u loose? i am just a first responder at work and we had a heart attack. his heart is beating but he can breath on his own. i feel....
i cant stop thinking about it
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