Case selected by the ANZASM Committee 

ENT

Case summary
An 81-year-old female resident of a nursing home presented to the ED with acute-on-chronic epistaxis. This was the sixth episode of epistaxis within a month; each requiring ED visits. One week earlier, silver nitrate cautery had been performed at the ear, nose and throat (ENT) department and the patient received two units of packed red blood cells for a haemoglobin level of 75g/L. Her GP discontinued the patient’s aspirin therapy after this. She had a medical history of Parkinson’s disease, hypertension, rheumatoid arthritis and previous carotid-cavernous fistula repair.

Ambulance staff reported intermittent left-side epistaxis and an estimated blood loss of 100ml prior to transfer. The initial ED management plan involved blood tests, continued pressure, and reassessment in 30 minutes. However, once pressure was released, bleeding resumed. ENT was consulted, and recommended administration of 1 gram of tranexamic acid (TXA), placement of a TXA-soaked Rapid Rhino nasal pack and subsequent review of the patient. Despite bloodwork being sent, haemoglobin was not documented in the ED notes. The patient was admitted to the short stay unit at 04:00. There was no surgical admission note.

At 07:00 during ward round, the ENT team reported ongoing epistaxis but did not document an oropharyngeal examination. The plan was to repeat the haemoglobin test and schedule an outpatient clinic review for nasal pack removal. No baseline haemoglobin was noted. The nursing notes indicate bleeding from both nostrils, and after unsuccessful attempts to contact the ENT team, the nursing team leader arranged a patient transfer for an in-person review at the ENT outpatient clinic.

At 11:30, the pathology lab reported a critical haemoglobin of 68g/L. The ENT team was notified, and a medical officer sent to manage the case. At this time, the patient’s systolic blood pressure had decreased from 190mmHg at admission to 110. It is unclear whether the ENT team was aware of the nursing team’s plan for outpatient review. The bedside nurse prepared the patient for transfer by wheelchair, but as she was assisted to the edge of the bed, she suffered a witnessed cardiac arrest.

The medical emergency response team arrived and initiated CPR. Blood was noted in the mouth. After five minutes, the patient exhibited agonal breathing and pulseless electrical activity. She was intubated, and blood was suctioned from the oropharynx and endotracheal tube. Following adrenaline administration, spontaneous circulation returned and one unit of packed red blood cells was transfused. 

A historical advance care directive outlined the patient's wish for ventilation but not resuscitation. A discussion between the ICU and ENT teams concluded discontinuation of resuscitation if further arrests occurred. Despite ongoing transfusion and ventilation, the patient developed progressive bradycardia and arrested again. Resuscitation ceased and the patient passed away.

Discussion
This case highlights the risks associated with seemingly routine epistaxis presentations, especially in high-risk patients. 

The failure to act on the haemoglobin levels is a key error. Despite prior episodes of epistaxis and a recent transfusion, the patient's haemoglobin was not documented or reassessed on admission. Haemoglobin should be promptly measured and acted upon, especially in patients with active bleeding and prior transfusions.

The lack of communication between the ED and ENT teams delayed critical intervention. Furthermore, the absence of an oropharyngeal examination left the patient vulnerable to aspiration from blood clots. 

Transferring the patient to an outpatient setting, despite her unstable condition, was inappropriate. Patients with active bleeding and hemodynamic instability should not be transferred to outpatient care. Immediate resuscitation and surgical intervention are required.

Clinical lesson
Oropharyngeal examination is essential in patients with epistaxis to check for clot debris or ongoing occult bleeding.

Clear and timely communication between medical teams ensures that critical information is acted upon promptly. Comprehensive documentation and coordinated care are essential for ensuring safe and effective patient management.