Epistaxis
- 1. By dr yasser mandour Epistaxis
- 2. Background Epistaxis is another name for what is commonly known as nose-bleeds It is an acute hemorrhage from the nostril, nasal cavity, or nasopharynx Common ED complaint, but 90% of patients can be treated with Occurs up to 60% of general population, but rarely leads to massive bleeding and death
- 3. Where does it happen? Two sources Anterior (more common) Posterior (typically common among old patients)
- 4. Causes Many different causes locally, systemically, and environmentally Environmental causes include allergens and humidity Can also be idiopathtic
- 5. Common local causes Chronic sinusitis Epistaxis digitorum (nose picking) Foreign bodies Intranasal neoplasm or polyps Irritants Medications Rhinitis Trauma
- 6. Common systemic factors Hemophilia Hypertension Leukemia Liver disease (e.g., cirrhosis) Medications Platelet dysfunction/Thrombocytopenia
- 7. Treatment Flow of blood normally stops when the blood clots To encourage blood clotting - Pinch the upper fleshy part of nose - Do so for 5-20 minutes - Tilt head forward can decrease the chance of nausea and airway obstruction from swallowing blood - Vasoconstrictive agents can also be used - Other products available to promote coagulation
- 8. Packing when simple treatment fails for anterior bleeding Anterior nasal cavity is packed from posterior to anterior with ribbon gauze that has petroleum jelly Bayonet forceps and a nasal speculum can be used to approximate accordion folding of gauze Each layer should be pressed down firmly before next layer is added Bayonet forceps Nasal speculum
- 9. Packing for posterior epitasis Done by Otolaryngologist A catheter is passed through the nostril and through the nasopharynx and out the mouth A gauze pack is at the end of the catheter The gauze pack is guide through the mouth and into the posterior nasal cavity
- 10. Other treatments Balloon packing Cauterization of blood vessel Laser therapy Embolization
- 11. Prevention Cooler house Vaporizer to return humidity and moisture to the air Nasal saline spray and water soluable jelly (especially for winter months) Avoid picking the nose or blowing the nose too vigorously. Do not strain to bend down or lift anything too heavy.
Editor's Notes
- Most cases of epistaxis occur in the anterior part of the nose, with the bleeding usually arises from the Kiesselbachs plexus. Posterior epistaxis generally arises from the posterior nasal cavity via branches of the sphenopalatine arteries. Such bleeding usually occurs behind the posterior portion of the middle turbinate or at the posterior superior roof of the nasal cavity. In most cases, anterior bleeding is clinically obvious. In contrast, posterior bleeding may be asymptomatic or may present insidiously as nausea, hematemesis, anemia, hemoptysis, or melena. Infrequently, larger vessels are involved in posterior epistaxis and can result in sudden, massive bleeding.
- - sinusitis: inflammation of the sinuses - Neoplasm is an abnormal mass of tissue as a result of neoplasia. Neoplasia is the abnormal proliferation of cells Rhinitis: stuffy nose, irritation and inflammation of some internal areas of the nose Medications (e.g., topical corticosteroids) Irritants (e.g., cigarette smoke)
- Systemic (spread system wide) Leukemia: lack of blood platelets Hemophilia refers to a group of bleeding disorders in which it takes a long time for the blood to clot. Platelet helps blood clot/Thrombocytopenia is any disorder in which there are not enough platelets. Hypertension - Uncontrolled high blood pressure makes highly vascularized areas (including the nose) prone to bleeding. Medications Medications that interfere with blood clotting, such as anticoagulants and non-steroidal anti-inflammatory drugs can make it easy for a nose to bleed. (e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory drugs)
- Packing of the anterior nasal cavity using gauze strip impregnated with petroleum jelly. A. Gauze is gripped with bayonet forceps and inserted into the anterior nasal cavity. B. With a nasal speculum, the first packing layer is inserted along the floor of the anterior nasal cavity. Forceps and speculum then are withdrawn. C. Additional layers of packing are added in an accordion-fold fashion, with the nasal speculum used to hold the positioned layers down while a new layer is inserted. Packing is continued until the anterior nasal cavity is filled. Packing should be removed in 48-72 hours
- Posterior nasal packing. A. After adequate anesthesia has been obtained, a catheter is passed through the affected nostril and through the nasopharynx, and drawn out the mouth with the aid of ring forceps. B. A gauze pack is secured to the end of the catheter using umbilical tape or suture material, with long tails left to protrude from the mouth. C. The gauze pack is guided through the mouth and around the soft palate using a combination of careful traction on the catheter and pushing with a gloved finger. This is the most uncomfortable (and most dangerous) part of the procedure; it should be completed smoothly and with the aid of a bite block (not shown) to protect the physicians finger. D. The gauze pack should come to rest in the posterior nasal cavity. It is secured in position by maintaining tension on the catheter with a padded clamp or firm gauze roll placed anterior to the nostril. The ties protruding from the mouth, which will be used to remove the pack, are taped to the patients cheek.
- Balloon packing: balloon is inflated with saline and sits in the posterior nasal cavity Doctor may use an endoscope to find the blood vessel needing cauterization. A chemical may be used such as silver nitrate Laser therapy: a laser beam seals the bleeding blood vessel Embolization: a special plug inserted into the bleeding vessel blocks blood flow
- Dryness may result in crusting, cracking, and bleeding of the nasal membranes