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Transport of a patient with massive traumatic epistaxis using a cricket helmet and posterior nasal packing.


In developing countries, when patients with traumatic epistaxis cannot be adequately treated at their local medical facility and require further treatment at a distant tertiary care center, it is important that bleeding be controlled before their transport. We describe a patient with a traumatic anterior ethmoidal artery bleed who needed to be taken to a tertiary care center 8 hours away for endoscopic ablation, which was not available at our hospital. The inflated balloon of an 18-Fr Foley catheter attached to the face guard of a cricket helmet was used as a posterior nasal pack. The patient arrived safely and was successfully treated. This case report illustrates that, in an emergency, readily available materials can be used to effect adequate tamponade of nasal bleeding so that a patient can be transferred safely. We believe this is the only such report in the literature.


Most traumatic epistaxis is self-limiting and can be controlled simply. Anterior nasal packing, posterior nasal packing, and greater palatine fossa injections have been described. (1) Bleeding that is not controlled by these methods necessitates further intervention, such as endoscopic ablation and embolization, (2,3) super-selective cauterization, (4) endoscopic clipping of the bleeding artery, (5) or endoscopic ligation. (6) In developing countries, facilities where these procedures can be performed are available only in tertiary care centers, and transport to these centers is not easy in the presence of active bleeding.

We describe a patient with a traumatic anterior ethmoidal artery bleed on whom a cricket helmet was used to provide traction after posterior nasal packing with a Foley balloon catheter. The patient survived the 8-hour journey by road to the referral center, underwent endoscopic ablation, and returned safely. We could not find a reference in literature for a similar transport modality.

Case report

A 28-year-old construction worker was hit on the face with an iron pipe. He did not lose consciousness, but he began to bleed profusely from his nose. He was brought to our institution within 30 minutes. On examination, his blood pressure was 120/70 mmHg and his pulse was 98 beats per minute (BPM). He was bleeding profusely from both nostrils, with the left nostril bleeding more than the right. He was fully conscious, oriented, and appropriately responsive. He had sustained no other injuries.

Preliminary anterior nasal packing was done, which failed to control the bleeding. Subsequently, an 18-Fr Foley catheter was used to perform posterior nasal packing on the left side; this slowed the bleeding. Preliminary x-rays showed no fracture. The bleeding resumed within I hour, and the patient's pulse rate climbed to 110 BPM and his blood pressure was 110/80 mmHg.

The patient was transfused with 1 unit of blood and advised that he should be taken to a tertiary care unit. However, he continued to bleed profusely. Traction on the Foley catheter was the only way to tamponade the bleeding. The tertiary referral center is 8 hours from our hospital on a winding hill road. There are no other centers en route where the patient could have been attended to if he had exsanguinated.

A cricket helmet was buckled onto the patient's head. The Foley catheter was tied to the face guard of the helmet under traction (figure), with the anterior nasal pack remaining in place, as well. The patient withstood the 8-hour road trip and reached the tertiary center safely without further hemorrhage. At the tertiary center, he underwent endoscopic ablation of the anterior ethmoidal artery, which was found to be torn and bleeding. He returned to our institution for follow-up, and 1 month after his injury was without complaints.


Though epistaxis is a very common emergency situation, seldom is it life-threatening and seldom do simple emergency measures fail to stop the bleeding. (7) Anterior epistaxis is responsible for 80% of bleeding, and nasal packing, which is easily undertaken in the emergency room, usually controls this. (8) Eight to 10% of epistaxis originates from the posterior nares; this is more troublesome and resistant to routine packing because of limited access to the bleeding site. In our patient, the site of refractory bleeding was the anterior ethmoidal artery at the skull base.

Traditional emergency surgery--such as exploration under anesthesia, thermal cautery or, in desperation, ligation of the internal maxillary or the internal carotid artery--has now been replaced by angiographic embolization and endoscopic ablation. (6) In countries where these procedures are not readily available, nasal packing must be performed before patients are transported to centers where they are available.

A variety of traditional methods and newer appliances have been described to control nasal bleeding. The Foley catheter is extensively used for this purpose. (9) Wrapping the catheter in gauze and impregnated, braided strips has been advocated to minimize the complication of alar necrosis. (10) A commercially available nasal tampon, the Rapid Rhino (ArthroCare Corp., Austin, Texas) also has been used with success. (11)

Once the patient is stabilized and has been transported to the tertiary care center, several treatment approaches can be used, such as transnasal endoscopic anterior ethmoidal artery ligation, (6) clipping of the bleeding artery, (5) cauterization, (4) or endoscopic ablation and angiographic embolization, (2,3) all of which have been reported to be successful.

We report this case to highlight the use of readily available materials to effect adequate tamponade of posterior nasal bleeding and allow for safe transfer. In our case, a cricket helmet's face guard served as a traction point that would move with the patient's head, ensuring that excessive traction would not occur. Our patient did not develop alar necrosis.


We have not been able to find similar reports in the literature. We believe that in a desperate situation, this innovative approach could be used as a lifesaving measure to transport a bleeding patient to a tertiary referral center for adequate control of refractory epistaxis.


(1.) Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician 2005;71(2):305-11.

(2.) Gurney TA, Dowd CF, Murr AH. Embolization for the treatment of idiopathic posterior epistaxis. Am J Rhinol 2004;18(5):335-9.

(3.) Ricci G, Molini E, Hamam M, et al. Treatment of severe epistaxis by superselective embolization: A review of 22 cases. Rev Laryngol Otol Rhinol (Bord) 2004;125(4):247-51.

(4.) Durr DG. Endoscopic electrosurgical management of posterior epistaxis: Shifting paradigm. J Otolaryngol 2004;33(4):211-16.

(5.) O'Flynn PE, Shadaba A. Management of posterior epistaxis by endoscopic clipping of the sphenopalatine artery. Clin Otolaryngol Allied Sci 2000; 25(5):374-7.

(6.) Srinivasan V, Sherman IW, O'Sullivan G. Surgical management of intractable epistaxis: Audit of results. J Laryngol Otol 2000; 114(9): 697-700.

(7.) Sparacino LL. Epistaxis management: What's new and what's noteworthy. Lippincotts Prim Care Pract 2000;4(5):498-507.

(8.) Pashen D, Stevens M. Management of epistaxis in general practice. Aust Fam Physician 2002;31(8):717-21.

(9.) Ho EC, Mansell NJ. How we do it: A practical approach to Foley catheter posterior nasal packing. Clin Otolaryngol Allied Sci 2004;29 (6):754-7.

(10.) Holland NJ, Sandhu GS, Ghufoor K, Frosh A. The Foley catheter in the management of epistaxis. Int J Clin Pract 2001;55(1):14-15.

(11.) Gudziol V, Mewes T, Mann WJ. Rapid Rhino: A new pneumatic nasal tamponade for posterior epistaxis. Otolaryngol Head Neck Surg 2005;132(1):152-5.

Philip V. Alexander, MS; Alka Walters, MS

From the Department of Surgery, Lady Willingdon Hospital, Himachal Pradesh, India.

Corresponding author: Dr. Philip V. Alexander, Lady Willingdon Hospital, Manali Kullu District, Himachal Pradesh, India 175 131.

Phone: 91-9816-033110; fax: 91-1902-252387; e-mail: philalexl@

Previous presentation: The information in this article was originally presented at the Association of Rural Surgeons conference; Mehsana, Gujarat, India; August 26-27, 2006.
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Comment:Transport of a patient with massive traumatic epistaxis using a cricket helmet and posterior nasal packing.(ORIGINAL ARTICLE)
Author:Alexander, Philip V.; Walters, Alka
Publication:Ear, Nose and Throat Journal
Article Type:Report
Geographic Code:1USA
Date:Jun 1, 2009
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