Epistaxis: Difference between revisions
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==Background==
==Background==
===Pathophysiology===
#Types
#90% anterior
##Anterior
#Kiesselbach plexus or Little area
###90% of nosebleeds
###Occur in anterior septum (Kiesselbach plexus)
###Can visualize with anterior rhinoscopy
##Posterior
###10% of nosebleeds
###Occur from sphenopalatine artery
###Cannot visualize
#Risk factors
##Digital trauma
##Rhinosinusitis
##Anticoagulant/antiplatelet use
##Trauma
##Neoplasia
##Hypertension (does not cause bleeding but prolongs existing bleeding)


===Misc===
==Diagnosis==
#Hypertension does not cause NBs but may prlong bleed; rx with analgesia and mild sedation
*Anterior versus posterior hemorrhage
#For severe or recurrent NBs or pts on Coumadin, have hepatic or renal dysfxn, consider CBC, Coags, T&S
**Assume posterior if measures to control anterior bleeding fail
#Posterior packing complications: hypoxia, hypercarbia, exacerbation of OSA, aspiration, hypertension, bradycardia, arrhythmias, MI, death
**Posterior bleeding assoc with:
***Coagulopathy
***Significant hemorrhage visible in posterior nasopharynx
***Hemorrhage from bilateral nares
***Epistaxis uncontrolled w/ either anterior rhinoscopy or anterior pack


==Treatment ==
==Treatment ==
#Apply anterior pressure
#Direct Nasal Pressure
#Start with 4 tongue blades and tape
##Have pt blow nose to expel clots or suction nose
#Ice pack
##Instill topical vasoconstrictor (oxymetazoline or phenylephrine)
#Gown up and gown the patient
##Have pt apply direct pressure to nose
#Kidney basin
###Pt leans forward w/ nares pinched between thumb and middle finger for 10-15min
#Chemical Cauterization
##Consider if two attempts at direct pressure fail
##Only perform if the bleeding vessel is adequately visualized
##Anesthetize w/ cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
##Once achieve bloodless field, place silver nitrate just proximal to bleeding source
###Leave on for only a few siconds
#Thrombogenic Foams
##Apply Gelfoam or Surgicel on visualized bleeding mucosa
##Bioabsorbable so removal is not needed
#Anterior Nasal Packing
##Only use if all of the above have failed
##Rapid Rhino
###Soak balloon w/ water and insert along the floor of the nasal cavity
###Inflate slowly with air until the bleeding stops
##Merocel
###Absorbent nasal tampon
###Coat tampon w/ water-soluble abx ointment and insert along floor of nasal cavity
###If tampon has not expanded w/in 30s of placement, irrigate it in place w/ NS
##Traditional Packing
###Apply ribbon gauze in accordion-like manner
#Posterior Nasal Packing
##Only consider if all of the above have failed
##Associated w/ higher complication rates (pressure necrosis, infection, hypoxia)
###Temporizing measure while awaiting ENT support
##Consider nasal block as posterior packing is often very uncomfortable
##All posterior packing should be accompanied by anterior packing
##Rapid Rhino
###Inflate posterior balloon
##Foley catheter w/ 30-cc balloon
###Lubricate w/ topical antibiotic
###Advance transnasally until visualized in posterior oropharynx
###Inflate balloon w/ 7cc of saline; retract 2-3cm until lodged in post nasopharynx
###Inflate w/ additional 5-7cc of saline to complete the pack


Stepwise approach - if successful do not proceed to next step...
==Disposition==
 
#Anterior Epistaxis
===ANTERIOR NB===
##Discharge after 1hr of observation
#Step 1: Clear nose of blood with suction or have pt blow nose
##Pts w/ therapeutic warfarin levels may continue medication
##Identify bleeding source with good light and speculum
##Discontinue NSAIDs for 3-4d
##Open speculum vertically; rest index finger of speculum hand on bridge of pts nose
##Precribe amoxicillin-clavulanate if anterior packing was placed
##If bleeding point cannot be localized, approx depth of bleeding can be localized using small Frazier suction catheter
##ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
##Place at nares and tilt pts head forward so that the sxn captures all bleeding
#Posterior Epistaxis
##Advance catheter posteriorly along the floor of the nose until blood returns from the nares and note depth
##Admission is strongly advised
#Step 2:
##Afrin spray (topical oxymetazoline): alapha agonist
##LET (lido 4%, epi 0.1%, tetracaine 0.4%) applied to cotton ball or gauze and remain in nares for 10-15mins
##Lidocaine 4% spray
##Topical cocaine HCL 4% or 10%
##Inject 0.5-1.0cc 1% lido in epi 1:100,000 with 27 gauge needle
#Step 3: Cautery
##Chemical cautery: silver nitrate for mild active bleeding or after bleeding has stopped (only one side of septum) cauterize on surrounding tissues first then upon source.
##If dry wet silver nitrate tip first
##Roll over area for 5-10s until grey eschar forms
##NosebleedQR: nonprescription powder of hydrophilic polymer and potassium salts – forms a crust.  Load onto an applicator swab and apply firmly to site b/g pinching nose for 15-20s
#Step 4: Nasal packing (if Step 3 fails)
##Merocel: (insert after adequate analgesia)
##Lubricate the TIP with antibiotic ointment (bacitracin) or surgical lubricant
###Insert with vertical orientation into nose at 45˚ 1-2cm then grasp merocel with bayonet forceps and rotate to horizontal plane and push all the way
###If the pack doesn’t rehydrate with blood may inject with NS or lido with epi or other vasoconstrictor
###Trim as necessary
##Epistaxis ballons: after checking balloon integrity lubricate copiously with viscous lidocaine or or water-based lubricant and insert
###Inflate balloons slowly; use NS if in place for duration >hours
###Rapid Rhino (inflatable balloon covered in carboxymethylcellulose hydrocolloid) that acts as a platelet aggregator and also forms a lubricant upon contact with water
####Soak in basin of sterile water for 30 seconds
####Inserted along septal floor and parallel to hard palate until fabric ring is well within the naris
####Inflate with 20cc syringe with air or NS
####Leave in place for 72h
###Surgicel or Oxycel (oxidized regenerated cellulose) and Gelfoam (absorbable gelatin foam) encourage platelet formation
####Place directly over bleeding site
###FloSeal is a biodegradable hemostasis sealant
####Works in anticoagulated patients – doesn’t require platelet aggregation
####Using forceps, place a moistened piece of gauze over FloSeal matrix for 1-2 minutes to ensure material remains in contact with bleeding tissue
####Begins to break down after 3-5days
###Thrombin-JMI Epistaxis Kit bovine derived topical thrombin
####Tradional packing: Sterile petroleum ribbon 0.5-1cm ribbon.
####Cover with abx ointment
####Grasp ribbon about 6cm from end with bayonet forceps and insert along floor of nose
####Remove speculum and place on top of ribbon and press down
####Grab ribbon 4-5cm from nasal alae and place in nose
####Once finished make sure both ends are protruding from nose
####Cover with gauze and secure with tape
 
===POSTERIOR NB===
#Transpalatal injection of the sphenopalatine artery
##Bend a 25-gauge needle at 2.5 cm
##Insert needle through the descending palatine foramen
###Medial to the upper second molar
##Aspirate
##Inject 1.5-2.0 ml of 1% lidocaine with epinephrine (1:100,000)
#Foley catheter (12 or 14F with 30cc balloon) lubricate then advance until tip and balloon are entirely in nasopharynx
##Fill the balloon with sterile saline (us 5-10cc) to allow it to be pulled snugly against the posterior nasal choana with anterior traction
##Secure in place with umbilical or c-clamp on the catheter
#Epistat has posterior balloon and anterior Merocel nasal tampon
#Storz T3100 nasal catheter has separate anterior and posterior balloons
##Insert then inflate posterior balloon with 5-10cc NS then pull forward gently until snug; inflate anterior balloon with 15-30cc NS
 
==Aftercare/Disposition==
#Observe for 1 hour after control of bleed no matter which treatment; encourage the pt to walk or perform other things that they would do at home
#F/U: stop ASA and NSAIDs for a few days
#If rx with cautery, Vaseline or a similar moisturizing agent should be applied liberally in the nose 3x/day for 7-10d to promote healing of friable mucosa and superficial vessels
#If nasal pack, prescribe analgesics, abx (Bactrim, Keflex or Augmentin) and f/u with ENT in 3days
#Avoid nose blowing, straingig, bending over, sports; nseeeze with mouth open
#Home humidifiers and saline nasal spray in drier, colder months
 
===Admission===
#Posterior packing: risk of airway obstrxn and subsequent hypoxemia and dysrhythmias
##Significant blood loss
##Abnormal vital signs
##Coagulopathies
##Refractory epistaxis
##Anterior packing with CHF, COPD


==Source ==
==Source ==
DeBonis 7/09
Tintinalli


[[Category:ENT]]
[[Category:ENT]]

Revision as of 19:24, 7 November 2011

Background

  1. Types
    1. Anterior
      1. 90% of nosebleeds
      2. Occur in anterior septum (Kiesselbach plexus)
      3. Can visualize with anterior rhinoscopy
    2. Posterior
      1. 10% of nosebleeds
      2. Occur from sphenopalatine artery
      3. Cannot visualize
  2. Risk factors
    1. Digital trauma
    2. Rhinosinusitis
    3. Anticoagulant/antiplatelet use
    4. Trauma
    5. Neoplasia
    6. Hypertension (does not cause bleeding but prolongs existing bleeding)

Diagnosis

  • Anterior versus posterior hemorrhage
    • Assume posterior if measures to control anterior bleeding fail
    • Posterior bleeding assoc with:
      • Coagulopathy
      • Significant hemorrhage visible in posterior nasopharynx
      • Hemorrhage from bilateral nares
      • Epistaxis uncontrolled w/ either anterior rhinoscopy or anterior pack

Treatment

  1. Direct Nasal Pressure
    1. Have pt blow nose to expel clots or suction nose
    2. Instill topical vasoconstrictor (oxymetazoline or phenylephrine)
    3. Have pt apply direct pressure to nose
      1. Pt leans forward w/ nares pinched between thumb and middle finger for 10-15min
  2. Chemical Cauterization
    1. Consider if two attempts at direct pressure fail
    2. Only perform if the bleeding vessel is adequately visualized
    3. Anesthetize w/ cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
    4. Once achieve bloodless field, place silver nitrate just proximal to bleeding source
      1. Leave on for only a few siconds
  3. Thrombogenic Foams
    1. Apply Gelfoam or Surgicel on visualized bleeding mucosa
    2. Bioabsorbable so removal is not needed
  4. Anterior Nasal Packing
    1. Only use if all of the above have failed
    2. Rapid Rhino
      1. Soak balloon w/ water and insert along the floor of the nasal cavity
      2. Inflate slowly with air until the bleeding stops
    3. Merocel
      1. Absorbent nasal tampon
      2. Coat tampon w/ water-soluble abx ointment and insert along floor of nasal cavity
      3. If tampon has not expanded w/in 30s of placement, irrigate it in place w/ NS
    4. Traditional Packing
      1. Apply ribbon gauze in accordion-like manner
  5. Posterior Nasal Packing
    1. Only consider if all of the above have failed
    2. Associated w/ higher complication rates (pressure necrosis, infection, hypoxia)
      1. Temporizing measure while awaiting ENT support
    3. Consider nasal block as posterior packing is often very uncomfortable
    4. All posterior packing should be accompanied by anterior packing
    5. Rapid Rhino
      1. Inflate posterior balloon
    6. Foley catheter w/ 30-cc balloon
      1. Lubricate w/ topical antibiotic
      2. Advance transnasally until visualized in posterior oropharynx
      3. Inflate balloon w/ 7cc of saline; retract 2-3cm until lodged in post nasopharynx
      4. Inflate w/ additional 5-7cc of saline to complete the pack

Disposition

  1. Anterior Epistaxis
    1. Discharge after 1hr of observation
    2. Pts w/ therapeutic warfarin levels may continue medication
    3. Discontinue NSAIDs for 3-4d
    4. Precribe amoxicillin-clavulanate if anterior packing was placed
    5. ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
  2. Posterior Epistaxis
    1. Admission is strongly advised

Source

Tintinalli

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