Chapter 23 - Epistaxis Flashcards
Things to consider with recurrent epistaxis and unidentifiable cause
coagulopathy vascular abnormality drug use hereditary disorders inflammatory and autoimmune conditions
4 ways to address posterior epistaxis
SPA ligation (most efficacious, cost-effective)
posterior packing
embolization
cautery
3 ways GPA can present to ENT
epistaxis
subglottic stenosis
hearing loss
Conditions to consider with refractory epistaxis, thrombocytopenia
DIC (underlying issue, sepsis) Massive hemorrhage thrombotic microangiopathy HIT ITP Bone Marrow Suppression
Next steps after posterior packing
Admit
Telemetry, pulse ox
Where does a JNA originate?
Medial PPF
General blood supply to nose
Ant Ethmoid - superior, septum
SPA- posterolateral wall, nasal cavity
Facial- anterior nasal cavity
4 initial steps to control mild epistaxis
1- gently blow nose (remove clots)
2- oxymetazoline
3- pinch alae against septum, hold for 10-15 minutes
4- cold compress on bridge of nose
Lean forward (to decrease blood down throat –> GI irritate/emesis/aspirate, to quantify better)
Signs of shock
anxiety cool/clammy skin oliguria/anuria weak pallor diaphoresis altered mentation
When to do endoscopy for eval of epistaxis
can’t see source on anterior rhin, suspect posterior on history, conservative not successful, suspect tumor/lesion
Two symptoms of blood loss
light head
SOB
When to obtain CBC for epistaxis eval
significant loss
repeated large episodes
coagulopathy
on anticoag
Causes of secondary epistaxis
Liver disease Heme dz Anticoag Trauma Neoplasm Recent Surgery Hereditary Illicit drugs Chronic medical issue Cancer
Materials you can use for anterior packing
Nasal tampon (with abx oint), then saline
Balloon/merocel
petroleum-impregnated gauze
Gelatin sponge wrapped in oxydized cellulose
How to apply silver nitrate
decongestant, pressure (slow bleeding, dry is better)
apply against mucosa at origin of blled until becomes gray (<10 sec)
periphery to center of bleed site
Finally, apply topical saline/decongestant to halt chemical reaction
How to place posterior pack
Red rubber tube into nose, through OP, retrieve with ring forceps
Attach cotton pack with silk ties to oral end, pull until rests in NP
May pack anterior as well
Fasten tube externally
Telemetry (risk arrythmia, syncope), pulse ox (may need supp O2), ABx
Possible complications of posterior packing
pain, respiratory difficulty
TSS, sinusitis
alar/septal necrosis
pharyngeal fibrosis/stenosis
Broad DDX new-onset nasal bleeding
Cold/dry air Trauma/Surgery URI, sinusitis, drugs, autoimmune Meds aneurysm septal deviation/perforation HHT Arteriosclerosis, HTN, blood dyscrasia, paraneoplastic, liver dz, platelets
Meds that may contribute to epistaxis
Aspirin/Anti Coag intranasal steroids nasal cannula O2 chemo Fish oil Evening primrose garlic cranberry juice vitamin E echinacea ginseng St. John's wort ginkgo biloba ginger kava saw palmetto
What to do if you suspect autoimmune cause of bleed
Look for signs of vasculitis
Test c-ANCA, ACE
If above negative, don’t need Bx
