Prophylactic antibiotics for anterior nasal packing in emergency department: A systematic review and meta-analysis of clinically-significant infections

BackgroundPatients presenting to emergency departments with spontaneous anterior epistaxis may undergo anterior nasal packing and sometimes receive systemic prophylactic antibiotics. There has not been sufficient evidence to support or refute this practice. The main objective of this study was to compare the likelihood of clinically significant infection (CSI) between patients with or without prophylactic antibiotics for anterior nasal packing due to spontaneous epistaxis.MethodsWe performed a meta-analysis of the literature to assess whether prophylactic antibiotics prevented CSI among patients with anterior nasal packing by searching PubMed, Embase, and Scopus databases for original articles. We also looked at the secondary outcome of non-infectious complications. We reported the outcomes using random effect models. Human studies in English, randomized control trials, quasi-randomized trials, clinical trials, retrospective studies, and case series were included. We excluded studies involving patients undergoing otolaryngologic surgeries. Statistical heterogeneity was examined using the DerSimonian and Laird Q test and I² statistic.ResultsA total of 281 articles were identified. Of these, 5 articles met inclusion criteria, with 383 patients receiving anterior nasal packing. One hundred sixty (42%) patients did not receive prophylactic antibiotics while 223 (58%) received antibiotics. The proportion of CSI in the pooled cohort was 0.8% (95% CI 0.2–1.9), resulting in a number needed to treat (NNT) to prevent one infection of 571. The rate of non-infectious complications associated with epistaxis was 20% (95% CI 10–32).ConclusionsThis meta-analysis suggests that prescribing prophylactic antibiotics for anterior nasal packing may not be necessary due to the low proportion of CSIs across heterogenous patient populations. Further high-quality randomized trials are needed to support this finding.     

Comparative Effectiveness of Topically Administered Tranexamic Acid Versus Topical Oxymetazoline Spray for Achieving Hemostasis in Epistaxis

BackgroundThe use of tranexamic acid (TXA) has recently gained popularity as a treatment modality for epistaxis in the emergency department. Previous studies have compared topical TXA to nasal packing. However, topical TXA has not yet been compared with topical oxymetazoline in the treatment of epistaxis.ObjectivesThis study compares the efficacy of the intravenous formulation of TXA applied topically vs. the vasoconstrictor oxymetazoline applied topically in achieving hemostasis in patients presenting to the emergency department with anterior epistaxis.MethodsIn this prospective study, patients presenting to the emergency department with the chief complaint of epistaxis, and meeting inclusion criteria, were allocated into 2 treatment groups; topical oxymetazoline vs. topical application of the intravenous preparation of TXA. Patients were assessed for time to hemostasis in the emergency department as well as the occurrence of rebleeding within the next 48 h after discharge.ResultsHemostasis was achieved in 14 (78%) of the 18 patients in the TXA group compared with 7 (35%) of the 20 patients in the oxymetazoline group. While there were occurrences of rebleeding in the emergency department before discharge and at 48 h in both groups, 11 patients in the TXA group had no recurrence of bleeding compared with 5 in the oxymetazoline group.ConclusionThis study demonstrated that the topical application of the intravenous preparation of TXA is more effective than topical oxymetazoline for achievement of hemostasis in anterior epistaxis. This has clinical significance toward preventing an avoidable need for escalation of treatment that could include applying nasal packing or cautery as well as preventing avoidable return emergency department visits. These outcomes would increase cost, potentially increase patient discomfort, and prolong emergency department throughput time.     

A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial

Objective

Epistaxis is a common problem in the emergency department (ED). Sixty percent of people experience it at least once in their life. There are different kinds of treatment for epistaxis. This study intended to evaluate the topical use of injectable form of tranexamic acid vs anterior nasal packing with pledgets coated with tetracycline ointment.

Methods

Topical application of injectable form of tranexamic acid (500 mg in 5 mL) was compared with anterior nasal packing in 216 patients with anterior epistaxis presented to an ED in a randomized clinical trial. The time needed to arrest initial bleeding, hours needed to stay in hospital, and any rebleeding during 24 hours and 1 week later were recorded, and finally, the patient satisfaction was rated by a 0-10 scale.

Results

Within 10 minutes of treatment, bleedings were arrested in 71% of the patients in the tranexamic acid group, compared with 31.2% in the anterior nasal packing group (odds ratio, 2.28; 95% confidence interval, 1.68-3.09; P < .001). In addition, 95.3% in the tranexamic acid group were discharged in 2 hours or less vs 6.4% in the anterior nasal packing group (P < .001). Rebleeding was reported in 4.7% and 11% of patients during first 24 hours in the tranexamic acid and the anterior nasal packing groups, respectively (P = .128). Satisfaction rate was higher in the tranexamic acid compared with the anterior nasal packing group (8.5 ± 1.7 vs 4.4 ± 1.8, P < .001).

Conclusions

Topical application of injectable form of tranexamic acid was better than anterior nasal packing in the initial treatment of idiopathic anterior epistaxis.     

Infective endocarditis of native valve after anterior nasal packing

We present a case report of a patient who was previously treated for spontaneous epistaxis with a petroleum jelly gauze (0.5 in x 72 in) anterior nasal packing filled with an antibiotic ointment, along with prophylactic oral clindamycin. The patient presented with fever and hypotension 3 days after the nasal packing. Her blood cultures grew methicillin-resistant Staphylococcus aureus and the transesophageal echocardiography showed vegetation on the atrial surface of the posterior mitral valve leaflet, confirming the diagnosis of bacterial endocarditis attributable to nasal packing. Several case reports discuss toxic shock syndrome after nasal packing, but none describe endocarditis of the native heart valves subsequent to anterior nasal packing. Current guidelines on endocarditis prophylaxis produced by the American Heart Association, European Cardiac Society, and British Cardiac Society together with published evidence do not recommend endocarditis prophylaxis for patients with native heart valves undergoing anterior nasal packing.     

How to stop a nosebleed

Epistaxis is a common emergency usually caused by local trauma to the nasal mucosa. Occasionally, it may result from systemic diseases such as atherosclerosis, hypertension, or coagulopathy. Anterior nosebleed often can be controlled with topical vasoconstriction and cautery. Intranasal packing may be necessary to tamponade bleeding vessels. Occlusion of the sinus ostia by anterior nasal packing may necessitate prophylactic use of antibiotics to prevent sinusitis. Posterior nosebleed requires nasopharyngeal packing. Patients must be closely monitored and given supplemental high-humidity oxygen. Persistent or recurrent nosebleed or failure of posterior nasopharyngeal packing to control bleeding indicates the need for otolaryngologic consultation and perhaps surgical intervention.     

鼻内镜下可吸收鼻窦药物支架手术对慢性鼻窦炎伴鼻息肉患者鼻腔菌群及预后的影响

目的 分析鼻内镜下可吸收鼻窦药物支架手术对慢性鼻窦炎伴鼻息肉患者鼻腔菌群及预后的影响。方法 选择2018年11月－2021年3月于该院耳鼻喉科就诊的80例慢性鼻窦炎伴鼻息肉患者纳入研究,依据随机数表法随机分为实验组和对照组,每组40例,对照组患者行鼻内镜Messerklinger微创手术,实验组患者在鼻内镜Messerklinger微创手术结束前将可吸收鼻窦药物支架置入。比较两组患者住院时间、鼻黏膜恢复时间及鼻腔恢复通气时间,以及不同治疗方式对于鼻腔黏膜菌群的影响,依据术后3周全部患者的临床表现进行疗效对比。结果 实验组住院时间、鼻黏膜恢复时间及鼻腔恢复通气时间均明显少于对照组（P < 0.05）。实验组术后鼻腔内弯曲杆菌属、肠球菌属阳性率明显低于对照组（P < 0.05）;实验组术后鼻腔内假单胞菌属、嗜血杆菌属、葡萄球菌属与对照组比较,差异无统计学意义（P > 0.05）。实验组术后治疗效果明显优于对照组（P < 0.05）。结论 鼻内镜下可吸收鼻窦药物支架手术治疗慢性鼻窦炎伴鼻息肉,可以明显促进鼻黏膜上皮化,降低术后患者鼻腔内弯曲菌属、肠球菌属阳性率,治疗效果显著,值得临床推广应用。     

Nebulized Tranexamic Acid for the Use of Epistaxis: A Case Report

BackgroundTranexamic acid is an antifibrinolytic agent and functions as a competitive inhibitor of plasminogen activation, promoting hemostasis. Topical application of tranexamic acid for the control of epistaxis has been described in the literature, mainly through administration with gauze and packing. There is limited evidence for the use of tranexamic acid via alternative routes of administration such as nebulization.Case ReportWe describe a patient who presented to the emergency department with epistaxis who was treated with nebulized tranexamic acid.Why Should an Emergency Physician Be Aware of This?Our case provides an alternative treatment modality using nebulizing tranexamic acid to help manage epistaxis in patients that cannot be managed with topical antifibrinolytic therapy administered by other means.     

The management of epistaxis in accident and emergency departments: a survey of current practice.

A short questionnaire on the subject of the management of epistaxis was sent to forty accident & emergency departments in two NHS regions. Thirty replies were received (response of 75%). It was found that all departments were involved in the initial management of epistaxis, but the extent of that involvement varied considerably. One of the most obvious factors contributing towards the degree of involvement was the liaison between the accident & emergency and the ENT departments. Three departments never referred patients to the ENT department for follow-up. Nine departments performed their own nasal cautery, but half of these did not use any form of local anaesthesia. Twenty-seven departments used various forms of nasal packing but, of these, two-thirds did not use any form of local anaesthesia. Twenty-three departments allowed patients to go home with a nasal pack in situ. The results of this survey are discussed and a guideline to the management of epistaxis in an accident & emergency setting is suggested.     

Use of Hemostatic Nasal Plugs in Emergency Medical Services in the Netherlands: A Prospective Study of 33 Cases

Background: Epistaxis is a common medical emergency with possible life-threatening complications. In the prehospital setting, epistaxis can be treated with nasal tampons. HemCon® Nasal Plug is a nasal tampon impregnated with oxidized cellulose, which has hemostatic properties. Objective: The objective of this study was to determine the effectiveness and usability of HemCon Nasal Plugs in the treatment of severe epistaxis in the prehospital setting. Methods: From June 2012 to December 2014, all ambulances of two emergency medical services in the Netherlands were equipped with HemCon Nasal Plugs. The plug was used according to protocol; if conventional treatment failed to control severe epistaxis or if conventional treatment was unlikely to achieve hemostasis. The ambulance personnel filled in an evaluation form after each use. Results: A total of 33 patients were treated with HemCon Nasal Plugs. Twenty-four patients were taking anticoagulants or suffered from a clotting disorder. The cause of epistaxis was idiopathic in the majority of the patients. Inserting HemCon Nasal Plugs resulted in cessation of epistaxis in 25/33 patients and resulted in reduction of epistaxis in 4/33 patients. HemCon Nasal Plugs failed to control epistaxis in 4/33 patients, possible due to an unreachable site of bleeding. Conclusion: This study demonstrated that HemCon Nasal Plug is an effective adjunct in the prehospital treatment of severe and uncontrolled epistaxis.     

Risk Factors for Recurrent Spontaneous Epistaxis

ObjectiveTo identify risk factors associated with spontaneous recurrent epistaxis.Patients and MethodsThis was a retrospective cohort study assessing patients in the Marshfield Clinic system diagnosed as having epistaxis between January 1, 1991, and January 1, 2011. There were 461 cases with at least 2 episodes of spontaneous epistaxis within 3 years and 912 controls with only 1 episode in the same time frame. More than 50 potential risk factors were investigated, including demographic features, substance use, nasal anatomical abnormalities, nasal infectious and inflammatory processes, medical comorbidities, medications, and laboratory values. A Cox proportional hazards regression modeling approach was used to calculate hazard ratios of epistaxis recurrence.ResultsTraditional risk factors for epistaxis, including nasal perforation, nasal septum deviation, rhinitis, sinusitis, and upper respiratory tract infection, did not increase the risk of recurrence. Significant risk factors for recurrent epistaxis included congestive heart failure, diabetes mellitus, hypertension, and a history of anemia. Warfarin use increased the risk of recurrence, independent of international normalized ratio. Aspirin and clopidogrel were not found to increase the risk of recurrence. Few major adverse cardiovascular events were observed within 30 days of the first epistaxis event.ConclusionCongestive heart failure is an underappreciated risk factor for recurrent epistaxis. Hypertension and diabetes mellitus may induce atherosclerotic changes in the nasal vessels, making them friable and more at risk for bleeding. Patients with recurrent epistaxis may also be more susceptible to developing anemia. Physicians should promote antiplatelet and antithrombotic medication adherence despite an increased propensity for recurrent epistaxis to prevent major adverse cardiovascular events.     

Intranasal foreign bodies: A 10-year analysis of a large cohort,in a tertiary medical center

BackgroundNasal foreign bodies (NFB) are commonly seen in pediatric patients seeking medical attention in the emergency department (ED). We aim to describe the occurrence, clinical presentation and management, of these cases, and to assess various risk factors for complications.MethodsA retrospective analysis of a computerized patient directory of 562 children admitted to the emergency department during a 10-year period, with NFB, in a tertiary pediatric hospital.ResultsUpon admittance, most of the children (82%) were asymptomatic. Among the symptomatic children (18%), the primary symptoms were nasal discharge (10%), epistaxis (8%) and pain (4%). Younger children (under 4 years) were more likely to insert organic materials, compared to older children. Younger children were also admitted sooner to the emergency department and were more likely to present with nasal discharge. The overall complication rate was 5%. None of the children had aspirated the foreign body. Complications included infection (2%), necrosis (0.7%), septal perforation (0.5%), deep mucosal laceration (1.5%) and loss of foreign body (1.9%). Significantly higher rates of symptoms and complications were associated with button batteries. Increased risk for complications were observed according to type of foreign body, multiple attempts to remove it, posterior insertion and left-side insertion.ConclusionsNasal foreign bodies in children are common. Mostly, patients are asymptomatic, therefore a high index of suspicion is required, for quick diagnosis and safe removal, without complications.     

The use of topical nonabsorbable gastrointestinal antifungal prophylaxis to prevent fungal infections in critically ill immunocompetent patients: a meta-analysis

OBJECTIVE: To investigate the preventive effect of topical nonabsorbable gastrointestinal antifungal prophylaxis on the incidence of fungal infection in critically ill immunocompetent patients. DATA SOURCE: Randomized controlled studies involving critically ill pediatric and adult patients in different languages from the Cochrane Controlled Trial Register (2004, issue 1), EMBASE, and MEDLINE databases (1966 to 30 April 2004) were included. Studies evaluating absorbable antifungal prophylaxis were excluded. Two reviewers assessed the quality of the studies and performed data extraction independently. DATA: Amphotericin B and nystatin were used as the nonabsorbable antifungal prophylaxis in the 15 studies included in this meta-analysis. Ten studies used a concomitant systemic antibiotic and four more studies used concomitant topical nonabsorbable antibiotics in the treatment group. Only one study compared topical nonabsorbable antifungal prophylaxis alone with placebo. The total incidence of fungal infections (relative risk [RR], 0.30; 95% confidence interval [CI], 0.18-0.48; p < .00001; extent of inconsistency [I(2)] = 0%) and proportion of patients with fungal infection (RR, 0.50; 95% CI, 0.28-0.87; p = .02; I(2) = 0%) were significantly reduced with topical nonabsorbable antifungal prophylaxis. The incidence of fungal urinary tract infection was significantly reduced (RR, 0.27; 95% CI, 0.10-0.74; p = .01; I(2)= 0%) but not fungal pneumonia (RR, 0.57; 95% CI, 0.28-1.16; p = .12; I(2)= 0%). Fungemia and catheter-related fungal sepsis were rare and not significantly reduced with nonabsorbable antifungal prophylaxis. The results remained unchanged in the sensitivity analyses after exclusion of studies with unclear study quality or exclusion of the contribution of fungal urinary tract infections to the total incidence of fungal infections. CONCLUSIONS: In critically ill immunocompetent patients who are at high risk of fungal infection, topical nonabsorbable gastrointestinal antifungal prophylaxis was associated with a reduced incidence of urinary fungal infections and a trend toward reduction in respiratory fungal infections and fungemia. Limitations in study data are such that many of these infections may have represented superficial infections of uncertain clinical importance; a large, randomized, controlled trial is needed to assess the cost-effectiveness and safety of topical nonabsorbable antifungal prophylaxis in critically ill patients.     

Topical tranexamic acid for the treatment of acute epistaxis in the emergency department

Objective

To evaluate the effectiveness and potential benefits of topical tranexamic acid (TXA) in the management of acute epistaxis.

国产高膨胀性海绵用于鼻腔填塞的临床观察

目的:比较两种鼻腔填塞材料的疗效,选择理想的鼻腔填塞物。方法:将324例鼻出血及鼻腔鼻窦术后患者分为凡士林纱条填塞组(A组)、国产高膨胀性海绵填塞组(B组)。结果:两组在止鼻出血方面疗效无显著性差异,但在鼻腔填塞后头鼻胀痛、取出填塞物后渗血量及粘膜情况有显著性差异(P<0·01)。结果:高膨胀性海绵是较理想的鼻腔填塞材料。     

鼻内窥镜下两种方法治疗鼻出血的疗效比较

目的：探讨鼻内窥镜下鼻出血的两种治疗方法的疗效：射频治疗法和止血材料填塞法。方法：比较分析从1999年8月～2002年7月经治的64例鼻出血患者的临床资料。结果：在鼻内窥镜下以射频治疗鼻出血。止血确切。免除鼻腔填塞。患者无痛苦。再出血率9．37％；以止血材料填塞治疗鼻出血。止血迅速。但患者填塞后有头痛及鼻胀感。并影响鼻窦通气引流。再出血率31．25％。结论：鼻出血的治疗应尽量避免鼻腔填塞；鼻内窥镜下射频治疗鼻出血是一种良好的治疗方法。值得临床推广应用。     

Medical and Nursing Staff Education Reduces Use of Prophylactic Ondansetron With Opioids in the Emergency Department

IntroductionWe aimed to evaluate the effect of a pharmacist-led educational intervention on administration of ondansetron in patients receiving IV opioid analgesia in the emergency department.MethodsThis study is a retrospective chart review undertaken in a single-community emergency department. During October and November 2015, emergency medicine pharmacists completed an educational initiative targeting medical and nursing staff designed to reduce prophylactic administration of ondansetron. The multifaceted educational initiative comprised of a link to an animated video, posters at strategic locations in the department, e-mail reminders, brief presentations during shift change, and 1-on-1 discussion (see https://www.youtube.com/watch?v=Uvx8zKJBCCI). All patients who received IV morphine or hydromorphone during September and December 2015 were identified using pharmacy dispensing records, and 150 patients from each period were randomly selected for retrospective chart review. The primary outcome was the change in the proportion of prophylactic administration of ondansetron with IV opioids for acute pain in the emergency department.ResultsThe proportion of patients administered prophylactic ondansetron decreased from 41% in the preintervention period to 26% in the postintervention period (difference 95% confidence interval [CI] 4.8 to 25.9, P = 0.005). Therapeutic use for documented nausea or vomiting upon presentation decreased marginally from 44% to 35% (difference 95% CI –2.3 to 19.7, P = 0.1). An overall decrease in the incidence of administration of ondansetron from 85% to 61% was observed (difference 95% CI 14.4 to 33.6, P < 0.001). No patient required rescue antiemetic administration.ConclusionsMedical and nursing staff education yielded a significant reduction in the administration of prophylactic ondansetron for patients receiving IV opioids in the emergency department.     

鼻内镜手术并发症与解剖因素关系探讨

目的 :探讨鼻内镜手术并发症与解剖因素的关系。方法 :分析我科 1995年至 2 0 0 2年间经鼻内镜手术治疗慢性鼻窦炎、鼻息肉 ,资料完整、随访时间达一年的病例 86 3例。结果 :轻微并发症出现率 5 2 % :包括眶周皮下淤血 5例、暂时性牙或唇麻木 15例、需要填塞的鼻出血 5例、引起症状的粘连 2 0例 ;严重并发症出现率0 5 8% :包括眶内积血 (中隔后 ) 1例、溢泪 2例、复视 2例。结论 :鼻窦CT扫描可清楚显示鼻腔、鼻窦解剖学异常与解剖变异 ,是预防大多数并发症的可靠依据 ,术者对术中解剖的熟悉程度以及熟练操作是避免并发症的关键。     

慢性上颌窦炎影响因素的CT分析

目的探讨窦口鼻道复合体病变及解剖变异与慢性上颌窦炎的关系.方法对CT诊断的52例单侧慢性上颌窦炎进行两侧对比分析.结果患侧与健侧筛泡截面分别为(77.75±33.51) mm2和(34±20.27) mm2(P<0.01).两侧分别有19个及10个大筛泡.患侧伴有32组筛窦炎,对侧21组.鼻息肉11例,单发于上颌窦炎侧9例,对侧仅1例,双侧1例.结论大筛泡、前中组筛窦炎症、鼻息肉与慢性上颌窦炎有关.     

Triage Standing Orders Decrease Time to Antibiotics in Neonates in Pediatric Emergency Department

IntroductionInfants aged 0 days to 28 days are at high risk for serious bacterial infection and require an extensive evaluation, including blood, urine, and cerebrospinal fluid cultures, and admission for empiric antibiotics. Although there are no guidelines that recommend a specific time to antibiotics for these infants, quicker administration is presumed to improve care and outcomes. At baseline, 19% of these infants in our emergency department received antibiotics within 120 minutes of arrival, with an average time to antibiotics of 192 minutes. A quality improvement team convened to increase our percentage of infants who receive antibiotics within 120 minutes of arrival.MethodsThe team evaluated all infants aged 0 days to 28 days who received a diagnostic evaluation for a serious bacterial infection and empiric antibiotics in our emergency department. A nurse-driven team implemented multiple Plan-Do-Study-Act cycles to improve use of triage standing orders and improve time to antibiotics. Data were analyzed using statistical process control charts.ResultsThrough use of triage standing orders and multiple educational interventions, the team surpassed initial goals, and 84% of the infants undergoing a serious bacterial infection evaluation received antibiotics within 120 minutes of ED arrival. The average time to antibiotics improved to 74 minutes.DiscussionThe use of triage standing orders improves time to antibiotics for infants undergoing a serious bacterial infection evaluation. Increased use, associated with nurse empowerment to drive the flow of these patients, leads to a joint-responsibility model within the emergency department. The cultural shift to allow nurse-initiated work-ups leads to sustained improvement in time to antibiotics.