From the Guidelines
The patient can be safely discharged with instructions for follow-up and wound care after packing removal, as her symptoms of improved pain and redness, and minimal discharge, are consistent with a normal healing process. Based on the clinical practice guideline for nosebleed (epistaxis) 1, the patient's packing has likely been in place for the recommended duration, and removal is appropriate. The patient's report of small amount of discharge on dressing is not uncommon, as nasal packing can cause nasal obstruction, decreased ability to smell, facial pressure, headaches, nasal drainage, and tearing from the eyes 1.
To reduce the chance of complications associated with packing, the patient should keep the nose and packing moist with nasal saline (salt water) sprays throughout the day, and strict adherence to follow-up instructions is necessary 1. The patient should be advised to avoid straining, lifting over 10 pounds, bending over, and exercising, and to sleep with the head slightly elevated to avoid increased blood flow to the nose and risk of further bleeding 1.
The patient should also be educated on symptoms that require prompt medical attention, including return of blood from nose or mouth, fever over 101°F, increasing pain, vision changes, shortness of breath or labored breathing, loss of color around the skin of the nose, swelling of the face, or a diffuse skin rash 1. After packing removal, the patient may initially experience a small amount of bleeding from the raw surfaces inside her nose, and keeping the nose humid with saline spray and moisturizing agents will prevent dry crusts and facilitate healing 1.
Key takeaways for the patient's care include:
- Continuing with daily wound cleaning using mild soap and water, followed by application of a clean, dry dressing
- Monitoring for signs of infection, including increased pain, redness, warmth, swelling, purulent discharge, or systemic symptoms like fever
- Avoiding activities that may increase blood flow to the nose and risk of further bleeding
- Keeping the nose humid with saline spray and moisturizing agents to facilitate healing.
From the Research
Patient Presentation
The patient is a 28-year-old female presenting for packing removal, reporting improvement in pain and redness, with no pain, fever, chills, or significant discharge, except for a small amount of discharge on the dressing.
Wound Management and Infection Prevention
- The use of topical triple-antibiotic ointment (TAO) has been shown to be effective in preventing infections in minor skin trauma 2.
- TAO is active against common disease-causing pathogens found in wounds and on the skin, and may be an attractive alternative to oral therapy in select circumstances 2.
- Studies have demonstrated that TAO maintains a wider spectrum of activity compared to mupirocin and is usable against mupirocin-resistant Gram-positive strains 3.
Packing Removal and Patient Outcomes
- The removal of packing has been shown to be effective in controlling liver bleeding in severe hepatic trauma, with a high survival rate in patients who underwent shortened perihepatic packing 4.
- In patients who underwent packing for severe blunt liver trauma, the removal of packing within 72 hours after laparotomy resulted in an 80% survival rate 4.
- The effectiveness of postoperative packing in FESS patients has been assessed, with absorbable packing found to be more effective than non-absorbable packing in reducing postoperative adhesion rate and more comfortable for patients 5.