Standard reviews of epistaxis in the emergency medicine literature center on the epidemiology, etiology, whether the bleeding is anterior or posterior, and methods by which bleeding can be controlled. As with other entities, management of the airway must take precedence. While unusual, nosebleeds may present with life-threatening airway compromise. This is a discussion of a potentially disastrous airway outcome.

Case

A 91-year-old Russian-speaking female on dual-antiplatelet therapy presented to the ED via ambulance with a left-sided nosebleed. She was reported to have had a mechanical fall, landing face forward without loss of consciousness, and has had a continuous nosebleed since then, per EMS and the home care provider.

On EMS arrival, it was noted that the patient had what seemed to be a controllable nosebleed with difficulty locating the source due to constant oozing. She was alert and awake with an intact airway. Due to her sole language being Russian, the initial history was limited. Vital signs on scene included heart rate 90, blood pressure 193/97, and 92 percent oxygen saturation. EMS placed her on non-rebreather at 10 L per minute due to the significant amount of bleeding through the nose, and brought her to the ED. On arrival she remained alert and oriented, sitting upright and face forward with an intact airway. The source of bleeding was identified as venous oozing out of the left naris, and she was spitting blood into an emesis basin. Her Glasgow Coma Scale was 15, and her vitals revealed she was afebrile, had mild tachycardia at 103 beats per minute, bradypnea, BP 189/95 and oxygen saturation varying between 88 and 93 percent on the non-rebreather. A translator was called; however, she was not answering questions appropriately per the translator’s dictation. Per discussion with family over the phone it was determined she had mild dementia, but had been feeling well prior to her mechanical fall. She had no history of anticoagulation, cerebrovascular accident, or myocardial infarction. Review of systems was unable to be obtained due to confusion.

Physical exam of the nasopharynx was difficult due to constant dark venous oozing of blood, with the oropharyngeal exam showing gross blood collections which she could clear on coughing and spitting. After clearing the nasal hemorrhage, an anterior source was ruled out based on lack of clot formation and oozing from a specific source. Posterior epistaxis from Woodruff’s plexus was assumed based on the dark-red consistency of the bleeding. Physical exam of the neck showed no fullness, erythema, or induration. She had a mild decrease in breath sounds to the bases; otherwise lungs were clear. The remainder of the exam was unremarkable.

Initial Management

The posterior nosebleed was initially addressed using gauze soaked in oxymetazoline with viscous lidocaine placed into the left naris, with no significant bleeding coming from the right naris. At this time, the patient started to have a larger amount of oropharyngeal contamination with gurgling and increased coughing. Assuming failure of the initial management strategy, the oxymetazoline-soaked gauze was replaced by a nasal packing soaked in tranexamic acid, and a nose clamp was applied. The external venous oozing was controlled; however, it was found that the patient was becoming lethargic and had decreasing mental status and oxygen saturations. Otolaryngology (ENT) was emergently consulted and the patient was brought to a resuscitation bay because of worry concerning possible aspiration secondary to posterior epistaxis, requiring further airway stabilization. Assuming a difficult airway, both a video laryngoscope and cricothyroidotomy kit were prepared at bedside. ENT arrived and placed bilateral nasal packing with 10-cm nasal packing. The non-rebreather was increased to 15 L per minute without initial bag-valve mask assistance due to concern for worsening an already aspirated airway.

She was kept upright until immediately before paralytic administration. The patient was transitioned to a reverse Trendelenburg position to keep the head upright, and direct laryngoscopy was performed. There was a significant amount of blood collecting in the laryngopharynx with rundown from the nasopharynx obscuring the vocal cords. These contents were suctioned vigorously. A DuCanto suction device was placed along the base of the tongue towards the upper esophageal inlet and left in place to continuously suction the airway, preventing further aspiration of gastric and nasopharyngeal contents utilizing the suction assisted laryngoscopy and airway decontamination (SALAD) technique. The laryngoscope blade was introduced shortly afterwards. Three attempts at passing the endotracheal tube were made, due to significant hemorrhaging from the nasopharyngeal area, anterior location of the vocal cords, and an anatomically small laryngeal opening.

It Was a Difficult Airway

After the third attempt at intubation, the vocal cords were visualized and a size 6.5 endotracheal tube was passed, with eventual airway stabilization. Blood continued to accumulate in the laryngopharynx, but was eventually stopped with the combination of bilateral nasal packing and constant suctioning. A total of 400 mL of blood was suctioned throughout the procedure

The SALAD Approach to Airway Management

The presence of contaminants in the airway has been shown to decrease first-pass success at intubation, regardless of whether direct or video laryngoscopy is employed.^1-7 Patients with significant blood, emesis and secretions seen during laryngoscopy can be alleviated by continually suctioning the hypopharynx, reducing the chance of failure to intubate.^8,9 The SALAD maneuver was developed to overcome the challenges faced during intubation of a massively contaminated airway.¹⁰ This technique is not only valuable for preventing aspiration of contents from the gastrointestinal system during intubation, but also those from nasopharyngeal sources such as epistaxis. Therefore, the SALAD approach should be considered in any instance where an aspiration risk exists, whether it be esophageal, nasopharyngeal, or oropharyngeal.

The SALAD technique is performed once the patient has been adequately sedated and paralyzed if necessary. Pre-oxygenation and standard intubation preparation are performed. Proactive suctioning of the airway is at the heart of this maneuver, utilizing a rigid suction catheter to decontaminate the airway of blood, fluid, or emesis prior to full insertion of the laryngoscope blade into the laryngopharynx. The suction catheter is left at the esophageal inlet, preventing aspiration of gastric contents, or in this patient’s case, nasopharyngeal blood. The laryngoscope is slowly inserted, preventing fogging or collection of fluid on the camera if utilizing a video approach to intubation. At this point, if there are continued fluid collections in the laryngopharynx, a second suction catheter can be utilized prior to attempting passage of the endotracheal tube. Once adequate secretions have been alleviated from the area, passage of the endotracheal tube can be done. Once the endotracheal tube has been secured, consistent suctioning must be ensured until the fluid collections have been controlled.

There are certain considerations that must be taken into account when utilizing the SALAD technique. Firstly, the physician should be proficient in this maneuver to avoid impeding the view of the vocal cords with the rigid suction device. Secondly, especially with significant hemorrhaging into the airway, monitoring of the volume of suctioned contents should be done. As in this case, 400 mL of blood had been suctioned in less than two minutes. Adequate replacement of blood products should be considered when massive hemorrhaging such as this occurs. Lastly, active suctioning for the entirety of an intubation attempt may lead to increased risk of hypoxemia. 10 Direct laryngoscopy is the preferred method of intubation when there is a large amount of fluid collected in the airway. Video laryngoscopy can be performed; however, there is a significant risk that the camera may become obstructed with the laryngopharyngeal contents, preventing an adequate view of the vocal cords. An additional operator should be present at the airway for any intubation deemed to be difficult, notably when using the SALAD technique.

The SALAD maneuver is an efficient approach to the airway where contamination with blood, secretions or emesis is suspected. With increasing literature favoring the use of this technique in the aforementioned circumstances, consideration of SALAD to secure the airway in high-aspiration-risk scenarios should be applied.

Dr. Glauser is professor of emergency medicine at Case Western Reserve University at MetroHealth Cleveland Clinic in Cleveland, Ohio.

Dr. Carvey (@MATTCARVEY123) is a second-year resident through the MetroHealth and Cleveland Clinic Foundation emergency medicine residency program in Cleveland, Ohio.

References

1. Prekker ME, et al. The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation. Crit Care Med. 2014;42(6):1372-1378.
2. Ohchi F, Komasawa N, Mihara R, Hattori K, Minami T. Evaluation of gum-elastic bougie combined with direct and indirect laryngoscopes in vomitus setting: a randomized simulation trial. Am J Emerg Med. 2017;35(4):584-588.
3. Mihara R, Komasawa N, Matsunami S, Minami T. Comparison of direct and indirect laryngoscopes in vomitus and hematemesis settings: a randomized simulation trial. BioMed Res Int. 2015;2015:806243.
4. Sackles JC, Corn GJ, Hollinger P, Arcaris B, Patanwala AE, Mosier JM. The impact of a soiled airway on intubation success in the emergency department when using the GlideScope or the direct laryngoscope. Acad Emerg Med. 2017;24(5):628-636.
5. Joshi R, et al. Difficult airway characteristics associated with first-attempt failure at intubation using video laryngoscopy in the intensive care unit. Ann Am Thoracic Soc. 2017;14(3):368-375.
6. Burns B, Habig K, Eason H, Ware S. Difficult intubation factors in prehospital rapid sequence intubation by an Australian helicopter emergency medical service. Air Med J. 2016;35(1):28-32.
7. Gaither JB, Spaite DW, Stolz U, Ennis J, Mosier J, Sakles JJ. Prevalence of difficult airway predictors in cases of failed prehospital endotracheal intubation. J Emerg Med. 2014;47(3):294-300.
8. Simons RW, Rea TD, Becker LJ, Eisenberg MS. The incidence and significance of emesis associated with out-of-hospital cardiac arrest. Resusc. 2007;74(3):427-431.
9. Choi I, Choi YW, Han SH, Lee JH. Successful endotracheal intubation using suction-assisted laryngoscopy assisted decontamination technique and a head-down tilt position during massive regurgitation. Soonchunhyang Med Sci. 2020;26(2):75-79.
10. Root CW, et al. Suction assisted laryngoscopy and airway decontamination (SALAD): a technique for improved emergency airway management. Resusc Plus. 2020;1-2:100005.