Sei sulla pagina 1di 34

EPISTAXIS

Common
Affects all age group
Nose supplied by internal and
external carotid arteries

AETIOLOGY

LOCAL CAUSES
TRAUMA

NASAL
DRYNESS

fractures
Selfinduced
Low
humidity
Cold

Rhinitis
INFLAMMATIO
infection
N

Nasal, sinus,
IATROGEN orbit surgery
Nasal spray
IC
Benign : polyps
TUMOR

Malignant : NPC

Sudden
Barometri movement to
c changes high altitude

Rhinosinusitis/polyp pictures

NPC pictures

SYSTEMIC CAUSES
COAGULOPAT
HY

VASCULAR

Drugs
Haemophilia, von
willebrand disease
Haematological
malignancy
Liver failure, uraemia
Hypertension/atheroscl
erosis
HHT

MANAGEMENT
1.
2.
3.
4.
5.

First aids
Cauterization
Nasal packing
Embolization
External carotid ligation

(proceed to the next step if the earlier


one fails)

Epistaxis: Management
STEP 1: First aids
1.
2.
3.
4.
5.

Relax! Stay calm


3Gs Gloves, Gown & Goggles
Resuscitate if necessary (ABC)
Patient should be sitting up & bending forward
Apply direct pressure for 10mins- pinch
cartilaginous part of nose, not the incompressible
nasal bones
6. Breath through mouth, spit blood/saliva into bowl.
Ensure blood not swallowed
7. Ice pack over the dorsum of nose may help

Epistaxis: Management
Applying direct
pressure to the
nose

A Incorrect

B Correct

In the mean time: get HISTORY


Quantify, characteristic, duration
Any signs/symptoms of anemia
Trauma?
Nasal symptoms?
Medication
Social: cocaine/ alcohol abuse

Lab test: FBC, coag, LFT, GSH/GXM


Large bore branula/IV lines

Examine using good


LIGHTING
SUCTION APPARATUS
SPECULUM

Look for source of bleeding ( anterior,


posterior or both)
BLEEDING SOURCE IDENTIFIED??

Epistaxis: Management
STEP 2: Cauterization
1. Chemical cautery: silver nitrate/trichloroacetic acid OR
electrocautery units
2. Explain the procedure to the patient
3. Inspect nasal cavity, clear out blood/clots
4. Spray nasal cavity with lidocaine (anaesthesia) &
phenylephrine (vasoconstrictor) to shrink nasal mucosa,
remain in place for 15mins
5. Ensure adequate illumination
6. Identify bleeding points
7. Apply the cautery for ~ 10 seconds
-. Tip of silver nitrate stick is rolled over mucosa until a gray
eschar forms
-. Electrocautery device reserved for aggressive bleeding,
done under LA or GA

If the source is not identified??


Bleeding too profuse

Epistaxis: Management
STEP 3A: Anterior
packing
-using
1. Ribbon gauze
impregnated with
bismuth iodoform
paraffin paste (BIPP)
or antibiotic oitment,
CMC
2. nasal tampon
(eg:rapid rhino, merocel)
Adrenaline not advisable

BIPP picture

HOW TO PACK
Ribbon gauze
packing
Pick the gauze with
forceps ~ 10-15 cm from
the tip
Pack the nasal cavity
starting from the floor
upwards, layering it until
the cavity roof is reached
Both ends of the ribbon
gauze should protrude
from the nostril
Secure the gauze

Epistaxis: Management
Merocel packing
Lubricate the Merocel
pack with KY jelly or
Naseptin cream
Insert the pack along
the floor of nasal cavity
Pack the other side as
well if involve both
Secure the string to the
cheek with tape
Once wet with blood, it
expands to fill the nasal
cavity

Nasal tampon picture


Merocel

Rapid Rhino

Still bleeding despite adequate


anterior packing??
Whats next??

Epistaxis: Management
STEP 3B: postnasal
packing

Brighton
balloon

Simpson
balloon

Foley
catheter

PICTURES

STEP 3B: postnasal packing


Remove the anterior pack and re-examine the nasal cavity. Do suction
when required.
With the patient breathing through mouth, insert the catheter horizontally
along the nasal floor
Once the tip passes beyond the palate into the OP, inflate the balloon to
fit in the posterior choana
Gently pull the catheter forward until resistance felt

Further management..

Nasal pack: kept 48 hrs


Antibiotics
CRIB
Correct the underlying pathology
Control BP
Correct coagulopathy

Removal of nasal pack..


After removal, observe in ward then
arrange for diagnostic endoscopy
If re-bleed, repack and arrange for
angiography +/- embolization (if
available)

Epistaxis: Management
Embolisation
Done by IR
endovascular treatment of epistaxis
through selective embolisation has
emerged as the treatment
of choice for persistent, intractable
epistaxis.

EPISTAXIS: Surgical management


Options
a) Endoscopically
EUA + endoscopic SPA ligation
EUA + IMAX ligation
b) Open
External caratid artery ligation

If the bleeding is from a tumour,


there s always an option of
hemostatic RT

Pope, L E R et al. Postgrad Med J 2005;81:309-314

THANK YOU

Potrebbero piacerti anche