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A previously healthy 16-year-old girl was involved in a motor vehicle crash and sustained multiple craniofacial injuries. On arrival to the emergency department, she was unconscious and intubated and had substantial bleeding from her nostrils and oral cavity. Physical examination revealed active profuse bleeding from her nasal cavities and from her mouth around the orotracheal tube. No lacerations were seen inside the oral cavity or the oropharynx. Her nasal cavities were then packed using a sterile 10-cm polyvinyl sponge (Merocel; Merocel Corp, Mystic, Connecticut) in each nostril and two 18×18-cm pieces of gauze in the nasopharynx. Initial blood workup revealed a hemoglobin level of 6.0 g/dL (to convert to grams per liter, multiply by 10.0). Blood transfusions were started.
Rameh C, Lavieille J, Magnan J, Deveze A. Radiology Quiz Case 2. Arch Otolaryngol Head Neck Surg. 2010;136(5):519. doi:10.1001/archoto.2010.61-a