Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

Wilderness and Rescue Medicine 198

eye drops and allow their eyes as many lens-free hours per day as possible. Nosebleed Most nosebleeds occur in an area of the anterior nostril called Kesselbach’s plexus. Bleeding from this area drains out of the nose if the patient is positioned upright with the head forward. When the bleed starts spontaneously, or because of nose picking, the problem is generally not seri- ous. Bleeding stops quickly with direct pressure. However, if the bleeding is the result of facial trau- ma, you should consider the possibility of facial bone fracture, which carries a risk of infection. In rare cases bleeding can originate in the pos- terior nasopharynx. Applying direct pressure without a nasal tampon or other device can be impossible. If a patient is using anti-coagulant medications, or even aspirin, bleeding can be significant.

inserted into the nostril for several hours. Soaking the tampon with a few drops of a decongestant nasal spray like oxymetazoline (the vasoconstric- tor in Afrin) reduces bleeding by constricting blood vessels in the nasal mucosa. The packing should be removed within four hours or so unless the patient can also be treated with prophylactic antibiotics. The frequency of nosebleeds from dry air and high altitude can be reduced by coating the inside of the nostril with Vaseline, antibiotic ointment, or a saline spray like Ayr Gel. Powdered clot- enhancers are available over the counter for nui- sance bleeding, including nosebleeds.

Nose Bleed

General Principles

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Treatment: • Direct pressure (squeeze nostrils x 15 minutes) • Nasal tampon with vasoconstrictor (Afrin) • Clot enhancing powders

Serious: • Associated fever, infection, or TBI • Profuse and persistent bleeding

Nose Bleed

General Principles

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Mechanisms: • Trauma • Nose picking • Dry air • Hypertension • Infection

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A nosebleed becomes serious when volume shock or airway obstruction is anticipated. If you cannot control a severe nosebleed in the field, make the patient as comfortable as possible and prepare for an urgent evacuation. If the patient needs to lie down, protect the airway by position- ing the patient face down or on his or her side with the chest and head supported to allow for drainage from the nose and mouth. Dental Problems Dental Trauma Loose teeth, tooth fragments, blood, and swol- len tissues can result in airway obstruction. The mechanism of injury can be associated with brain and spine injury. Pain can produce acute stress reaction (ASR). Swallowing blood can cause vom- iting. The primary assessment of dental trauma

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Treatment of Nosebleed Position the patient sitting forward or lying face down to allow for drainage out of the nose rather than down the throat. Instruct the patient to blow out any clots, then pinch the nostrils together and hold firmly for 15 minutes. This applies simple direct pressure to the most likely bleeding source. Like any bleeding, it is essential to hold enough pressure for a long enough time. This will stop most nosebleeds that you are likely to see. Persistent bleeds can be treated with nasal pack- ing. A light-flow (small size) tampon can be gently