Prescribe an antibiotic for patientstreated as outpatients with nasal packing due to the risk of toxic shock syndrome and sinusitis
Prescribe an antibiotic for patientstreated as outpatients with nasal packing due to the risk of toxic shock syndrome and sinusitis: Excerpt from Avoiding Common Pediatric Errors
Author:
William Giasi, Jr., MD
What to Do - Take Action
The rich vascular network of the nose makes it vulnerable to either spontaneousbleedsorbleedssecondarytotrauma.Inthemajorityofcases,epistaxis
is mild and self-limiting. Epistaxis can result from local or systemic causes.
Common etiologies of epistaxis include upper respiratory infection, sinusitis, local trauma, foreign bodies, irritants, and medications. Less common
etiologies include vascular malformations, leukemia, thrombocytopenia, coagulopathies, or hepatic disease.
Anterior bleeds arise from the rich venous vascular network on the
anterior nasal septum, the Kiesselbach plexus, and account for the majority
of episodes. The thin and adherent nature of the anterior venous plexus
makes it especially susceptible to trauma. The venous source of anterior
bleeds results in a slow and oozing quality. In contrast, posterior bleeds occur
less often and arise from branches of the sphenopalatine artery. The arterial
source results in more profuse bleeds that may drain into the nasopharynx,
thus carrying a higher risk of airway compromise.
Epistaxis generally requires minimal intervention. Those patients who
are not actively bleeding should be given anticipatory guidance to avoid local
trauma as well as to keep the mucosa moist. If a patient is actively bleeding,
there are several management options that lie along a continuum ranging
from conservative to invasive surgical interventions.
Patients should be instructed hold keep their head elevated and to pinch
the nose without interruption for at least 5 minutes and up to 20 to 30
minutes. Hyperextension should be avoided to prevent aspiration of blood.
In the event that a bleed doesn't resolve with simple pressure, the clinician
can place a piece of gauze soaked in either nasal decongestant in the anterior
nasal cavity, followed by direct pressure. If bleeding remains active, chemical
cauteryusingsilvernitrateorthermalcauterymaybehelpful.Epistaxisthatis
unresponsive to cautery may require anterior nasal packing with petroleum
jelly gauze strips or commercial packing that are used to tamponade the
vessels. Posterior bleeds are less responsive to cautery and often require the
use of either nasal packing or balloons.
The presence of nasal packing may serve as a medium for bacteria
growth. Application of antibiotic ointment to the packing as well as an oral
course of prophylactic antibiotics, with Staphylococcus coverage, may decrease infection. Patients with nasal packing should be closely monitored
for complications such as sinusitis or toxic shock syndrome. Although it is
uncommon, toxic shock can result in multiple organ failure and ultimately
death. Early recognition of complications, removal of the packing, and initiation of appropriate management is important.
Suggested Readings
Bernius M, Perlin D. Pediatric ear, nose, and throat emergencies. Pediatr Clin North Am.
2006;53(2):195–214.
Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005;71(2):305–311.
Epistaxis. In: Cummings CW, Flint PW, Haughey BH, et al. eds. Otolaryngology: Head & Neck
Surgery. 4th ed. Philadelphia: Mosby Inc., 2000, pages 942–960.
Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005;71(2):305–311.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Toxic Shock Syndrome
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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