Name
EPISTAXIS
DESCRIPTION
DETAIL
CAUSES : * IDIOPATHIC * LOCAL CAUSES - - TRAUMA TO LITTLE AREA - DRYNESS OF NASAL MUCOSA - ABNORMAL ANATOMY LIKE DNS - ULCERATIONS & EXCORIATIONS - NASAL FRACTURE - TUMORS OF NOSE OR SINUSES - SEPTAL GRANULOMAS & PERFORATIONS - FOREIGN BODY * SYSTEMIC CAUSES - COAGULOPATHY LIKE A. HAEMOPHILIA B. CHRISTMAS DISEASE C. VON WILLEBRANDS DISEASE D. PURPURA E. LEUKEMIA - HYPERTENSION - DRUGS LIKE ANTICOAGULANTS , ASPIRIN, CYTOTOXIC DRUGS - ATHEROSCLEROSIS - HEREDITARY HAEMORRHAGIC TELANGIECTASIS - VITAMIN DEFICIENCY - VIT C , VIT K - RENAL DIALYSIS β’ Bleeding originating in a sinus (fracture, tumor) β’ Endometriosis (nasal ectopic endometrium) β’ Neoplasm (especially when unilateral) β’ Traumatic/blunt - nose picking (epistaxis digitorum) low humidity foreign bodyDIAGNOSTIC PROCEDURES β’ Angiography (rarely) β’ Nasal endoscopy to locate and cauterize bleeding vessel
TYPENOTES
APPROPRIATE HEALTH CARE : β’ Outpatient (usually). Inpatient for severe hemorrhage. β’ Elderly patient with posterior bleeds and balloon or packing usually requires inpatient management GENERAL MEASURES : β’ Resuscitation as indicated β’ Sedation, analgesic, antihypertensive or anticoagulant reversal as needed β’ Patient should be gowned and sitting, if stable. Gown, gloves, and eye protection for examiner. β’ Attempt to locate bleeding site using headlamp, suction, nasal speculum and assistant. Clear nasal cavity of blood with suction, forceps withdrawal of clot or patient blowing nose. If bleeding has stopped, rub suspicious areas with wet cotton tipped applicator to identify site. Diffuse ooze or multiple sites suggests systemic cause. In cases of posterior bleed try to identify as either roof or low posterior site since each has different arterial supply (will be important if arterial ligation is necessary). β’ Locating the site may be difficult with bilateral bleeding. Usually there is only one bleeding site and the blood appears on the other side because of (1) septal perforation, (2) obstruction of the affected side by pinching or packing or (3) there is a posterior bleed and blood passes behind the nasal septum. Clues are the side on which bleeding started and a careful examination using suction, headlamp and speculum. 1. Anterior bleed: . Place pledget soaked in vasoconstrictor and local anesthetic in cavity and pinch nostril for several minutes to stop bleeding by direct pressure . Remove pledget and visualize vessel. Cauterize with silver nitrate stick directly on vessel with firm pressure for 30 seconds. . Alternative chemical cautery includes bead of chromic acid or 25% trichloroacetic acid. Larger vessels respond better to thermal cautery or bipolar electrocautery. Avoid indiscriminate cauterization of a large area. . If unsuccessful, apply second dose of anesthetic and place anterior pack using 1/2 x 72 inch ribbon gauze impregnated with petroleum jelly (Vaseline) or nasal tampons may be used. Use bayonet forceps and nasal speculum to insert in folding layers as far back as possible. Press each layer fi rmly down on the last in one continuous strip with the folded ends alternating front and back. The average nasal cavity will accommodate the full length if properly placed. Tape 2x2 gauze over nostril as drip catch and to prevent packing end from falling out of nostril. 2. Posterior bleed: . Traditional posterior packing has been replaced by various balloon systems. However it is very effective if balloon systems fail to control bleeding. . Balloon systems include single large balloon with or without central tube for airway. They usually come in 3 or 4 sizes and right or left. Other systems provide a small (10 cc) posterior balloon and larger (30 cc) anterior balloon. After local anesthesia, the tube is placed in the affected nostril and is passed to the nasopharynx as one would a nasogastric tube. Then infl ate the posterior balloon with air or water (see manufacturers directions) and pull forward to press upon the posterior area. Then infl ate the anterior balloon (see note under Complications) . A very effective method uses a 10 to 14 Fr Foley catheter. Place tip of Foley through the nostril to nasopharynx or upper oropharynx. Visualize through mouth avoiding placement in hypopharynx. Inflate balloon 7 to 15 cc. Pull forward until balloon wedges in posterior passage. Assistant maintains gentle traction while catheter is placed along mid-section of lateral wall of nasal cavity. Insert anterior pack described above. Maintain catheter traction and stretch slightly. Place umbilical cord clamp on catheter across nostril against anterior pack so that elasticity of catheter compresses balloon against anterior pack. Protect facial skin from clamp by padding with 2x2 gauze. Drape rest of catheter over ear and tape in place. 3. Intractable bleed: . Bilateral packing is sometimes required (admission required) . Bleeding from roof may be controlled by placing double balloon system with small anterior pack placed above anterior balloon. Inflation then raises pack to place pressure on roof. . Intractable bleed requires surgical cauterization or arterial ligation (ideally after visual identification of bleeding site to define appropriate arterial supply). This can usually be achieved through transnasal endoscopy. Alternative is angiographic selective arterial embolization. SURGICAL MEASURES : . Arterial ligation for intractable bleeding ACTIVITY : Bedrest with head at 45 to 90 degrees DIET: No alcohol or hot liquids PATIENT EDUCATION : Demonstrate proper pinching pressure techniques DRUG(S) OF CHOICE : . Vasoconstrictors : . Cocaine 4% . Phenylephrine 0.25%, . Xylometazoline 0.1% . Epinephrine 1:1000 . Anesthetics : . Cocaine 4% . Tetracaine (Pontocaine) 2% . Lidocaine laryngeal spray, jelly 2%, solution 4%, viscous 2% . Systemic antibiotics and decongestants to prevent sinusitis with packs or balloon use . Iron supplementation for patients with considerable blood loss PATIENT MONITORING : Hemodynamics and blood loss as indicated. Packs or balloons removed in 24 to 36 hours. PREVENTION/AVOIDANCE: Liberal application of petroleum jelly (Vaseline) to nostril to prevent drying and picking. Humidification at night. Cut fingernails. POSSIBLE COMPLICATIONS: β’ Sinusitis β’ Double balloon systems tend to migrate posteriorly, if anterior balloon breaks, patient may obstruct airway with migrated posterior balloon. Prevent by placing umbilical cord clamp across end of tubing at nostril after inflation. β’ Septal hematoma or abscess from excessive trauma during packing β’ Septal perforation secondary to aggressive cauterization β’ External nasal deformity secondary to pressure necrosis from the anterior component of posterior packing β’ Mucosal pressure necrosis secondary to high balloon inflation pressures β’ Cocaine, lidocaine toxicity β’ Vasovagal episode during packing EXPECTED COURSE/PROGNOSIS : Good results with proper treatment
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
BLEEDING TIME, CLOTTING TIME, PROTHROMBIN TIME, PARTIAL THROMBOPLASTIN TIME, THROMBIN TIME, FIBRINOGEN, BLOOD UREA, COMPLETE BLOOD COUNT, CT SCAN