Epistaxis - A Medical Guide PDF

EPISTAXIS DR.SHORASH SINDI FIBMS(ENT) Bimodal: common in age 50 years. more in winter and early morning. Blood could come from nasolacrimal duct with nausea and vomiting If severe. Anterior: more common. more in children and young adult. Posterior: less common, more in old people, more likel...

EPISTAXIS DR.SHORASH SINDI FIBMS(ENT) Bimodal: common in age 50 years. more in winter and early morning. Blood could come from nasolacrimal duct with nausea and vomiting If severe. Anterior: more common. more in children and young adult. Posterior: less common, more in old people, more likely to require medical attention. General 1 Bleeding disorders (Coagulopathy, Platelet disorders) 2 Drugs: aspirin, anticoagulant. 3 Idiopathic: as sarcoidosis Local 1 Idiopathic: Most common 2 Trauma as nose picking, nasal blowing and sneezing, NG tube. 3 Neoplasim as Inverted papilloma, Angiofibroma, Sq. C CA 4 Topical medication: steroid, Cocaine. Initial first aid measurements clean & hippocratic technique, if no response → simple cautery, admit Assessment of blood loss vitals, sweating, pallor, IV line, cross match & baseline PCV Evaluation of the cause onset, duration, frequency, amount, side, type, MHx, FHx, DHx Procedures to stop continued bleeding cautery, anterior & posterior packing, ESPAL, embolization, maxillary or ECA ligation, sedation DEFINITION wire bleeding Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx. It is a frequent ED complaint and often causes significant anxiety in patients and doctors. usually noticed o when the blood drains out through the nostrils.  opthalmic from I maxa 0 MOXA I. Anterior: more common. More in children and young adult. II. Posterior : q Less common. Aspiration oralcavity q more likely to require medical attention q More in old people. Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting. q Extremely common q Affect all age groups q Prevalence 10-12% q Age :bimodal distribution, with incidence peaks at ages younger than 10 years and older than 50 years. q Sex: no sex predilection exists. q More in winter season oontknow not the actual cause I di II mine more bleeding likely q Local 1. Idiopathic: Most cases of epistaxis do not have an easily identifiable cause. 2. Trauma : v Nose picking General 1. Bleeding disorders (Coagulopathy, Platelet disorders) v Nasal blowing and sneezing. 2. Drugs: aspirin, anticoagulant. v NG tube. 3. Idiopathic: as sarcoidosis v Trauma to sinus,orbir and skull base. Local v Barotrauma. 1. Idiopathic: Most common 2. Trauma as nose picking, nasal blowing and sneezing, NG tube. v Iatrogenic. 3. Neoplasim as Inverted papilloma, Angiofibroma, Sq. C CA 4. Topical medication: steroid, Cocaine. 3. Neoplasim Ø Inverted papilloma Ø Angiofibroma Ø Sq.c ca 4. Topical medication :steroid, Cocaine. q General 1. Bleeding disorders: Ø Coagulopathy Ø Platelet disorders 2. Drugs: aspirin, anticoagulant. 3. Idiopathic: ex :sarcoidosis. HYPERTENSION AND EPISTAXIS The relationship between hypertension and epistaxis is implicated. Epistaxis is more common in hypertensive patients, and patients are more likely to be acutely hypertensive during an episode of epistaxis. Hypertension, however, is rarely a direct cause of epistaxis, and therapy should be focused on controlling hemorrhage before blood pressure reduction. Epistaxis ➞ stress and anxiety ➞ Release of Adrenaline ➞ activate sympathetic system ➞ ↑ BP  Epistaxisalone MANAGEMENT OF EPISTAXIS isnevera muse You I. initial first aid measurement. II. Assessment of blood loss. Pallor LOP III. IV. Evaluation of the cause(s). Procedures to stop continued bleeding. ABQ Initial first aid measurements clean & hippocratic technique, if no response → simple cautery, admit Assessment of blood loss vitals, sweating, pallor, IV line, cross match & baseline PCV Evaluation of the cause onset, duration, frequency, amount, side, type, MHx, FHx, DHx Procedures to stop continued bleeding cautery, anterior & posterior packing, ESPAL, embolization, maxillary or ECA ligation, sedation  SOCRATES IN ANY CASE OF EPISTAXIS, IT IS IMPORTANT TO KNOW: 1.Mode of onset. Spontaneous or fingernail trauma. 2.Duration and frequency of bleeding. 3.Amount of blood loss. 4.Side of nose from where bleeding is occurring. GEE 5.Whether bleeding is of anterior or posterior type. 6.Any known bleeding tendency in the patient or family. 7. History of known medical ailment (hypertension, leukaemia, mitral valve disease, cirrhosis and nephritis). 8.History of drug intake (analgesics, anticoagulants, etc.). I. INITIAL FIRST AID MEASURE qPinch the nose tightly. q Up right position to decrease BP. q Lean forward to avoid swallowing If epistaxis not responds to these measure or 0 simple cauterization then admit to hospital and go to the next steps Epistaxis never cause shock ASSESSMENT OF BLOOD LOSS PR BP Look for pallor and sweating Insert I.V line. PRT Cross matching. B fit Baseline PCV.  Wear gloves, gown and eye protection Good light Patient is comfort. Thorough cleaning of the nose Rapid informative HX v Character of epistaxis v Medical and drug History v Social Hx. (cocaine abuse). v Exposure to toxin v Recent surgery or trauma to the nose PROCEDURES TO STOP BLEEDING Topical anaesthesia and vasoconstruction. If bleeding point is accessible and bleeding is not brisk thencauterized either Chemically eg. silver nitrate is helpful in cases of mild bleeding. The tip of silver nitrate stick should be held in contact of bleeding site for several seconds. The cauterized area becomes grayish-white in color. Electrical monopolar, bipolar or suction cautery not used Laser for vascular mal formation Endoscope use for more posterior site Endoscopic nasal cautery: Posterior bleeding points are seen and cauterized better under endoscopic vision. With the help of suction cautery, the procedure may be done successfully under local anesthesia and sedation INDICATIONS OF CAUTERY Minor and single bleeding Easily visualized Advantages Easy Quick No packing Disadvantages Superficial coagulation Cartilage exposure Perforation so avoid bilateral cauterization at same time not  ANTERIOR PACKING: § Indication: acute or recurrent bleeding not respond to medical or cauterization. § Types: Vaseline ribbon gauze, BIPP. Merocel Pope or Kennedy nasal sponges, Gelfoam, Surgicel. Systemic antibiotics are started to prevent infection and toxic shock syndrome Keep for 48-72 hrs. without AB and more with it 0 BIPP: Bismuth Iodoform Paraffin Paste, can be left for 5 days without antibiotics  0 Must always be with POSTERIOR NASAL PACKING anterior packing ❑Indications: 1. Failed anterior Packing 2. Bleeding from major branch of Sphenopalatine artery ❑ Types: gauze impregnated with BIPP, Folley catheter, nasal balloon. ❑ Antibiotics is Mandatory to avoid toxic shock syndrome  If bleeding continue despite all these measures, then exam under GA. Never forget to correct the primary cause. Other measure: Embolization Arterial embolization is done in refractory cases of epistaxis. It is an invasive process and performed in angiography suite by an experienced radiologist. Endoscopic spheropolontine Artery ligation Arterial ligation. 1. External carotid artery 2. Maxillary artery 3.ESPAL In fact, this technique is now often recommended as the first-line surgical treatment when more conservative measures have been unsuccessful. ESPAL Endoscopic sphenopalatine artery ligation Role of Sedation O A dose of 50-100 mg of pethidine inj. to allay the fear and anxiety of the patient.