CNS/ HN - Epistaxis Flashcards
Differentials of Epistaxis
- Renal Artery Stenosis
- Ddx
Differential Diagnosis - Local: o Idiopathic o Intracranial tumors o Rhinitis o Trauma (nose picking/foreign body) o URTIs (common cold, flu, sinusitis) o Deviated nasal septum
- Systemic:
o Blood d/o
o CVS (arteriosclerosis, HTN—if very severe)
o Drugs: anticoagulants, ASA, intranasal steroids
o Hereditary hemorrhagic telangiectasia
o Systemic febrile infections (malaria)
o Toxic agents - Environmental factors: very high temperature
Epistaxis- Key History
Recent trauma to nose.
Significant past history (e.g. hypertension).
Drug and alcohol history (e.g. anticoagulants).
Bleeding or bruising tendency.
Epistaxis - Key PE
Nasal airways and sinuses
•Skin for evidence of purpura or ecchymoses
•Lymph node areas and abdomen for hepatosplenomegaly
•Vital signs (esp. blood pressure)
Epistaxis - Key Investigations
Probably none. Consider: •FBE •clotting studies •sinus X-ray •INR •CT scan (occasionally)
Epistaxis - Key Diagnostic Tips
Diagnostic tips
•Recent onset of persistent bleeding in elderly points to carcinoma.
•Severe epistaxis is often caused by liver disease coagulopathy.
•Difficult-to-control posterior bleeding is a feature of the hypertensive elderly.
History - Epistaxis Ddx
History:
- Is my patient hemodynamically stable?
- HOPI -
- When did it start?
- Is it coming from one or both?
- on and off or continuous?
- How long did it last?
- Did it have any blood clots?
- Did it stop spontaneously?
- Is it the first episode?
- Do you notice that the blood is trickling or going down the throat?
- ASSOCIATED SYMPTOMS
- Any nausea/vomiting?
- Any headache?
- Any fever?
DDX/RISK FACTORS
- Any trauma to the nose?
- Did it come after picking of the nose or sneezing?
- Hot Weather?
- Any recent URTI?
- Do you have allergic rhinitis or sinusitis?
- Any anatomical abnormalities like deviated nasal septum?
- Any foreign body in the nose?
- Did you notice any mass inside the nose?
- Do you bruise easily?
- Do you have any change in the color of stool or urine?
- Medications - ASA, Nasal sprays
- PMHx: Do you have any known medical condntions like heart disease, hypertension, or liver disease?
- Any recent surgery?
- Medications? Allergies?
- Any bleeding disorders?
- How are your periods?
- Any FHx of any bleeding disorders?
- SADMA?
Physical Examination - Epistaxis Ddx
Physical examination:
- Spray with local anesthetic and vasoconstrictor – cophenylcaine forte spray (Lignocaine + phenylephrine)
- ENT exam: clean the nose using suction or swab. Use nasal speculum and good lighting to look at the source of bleeding or any other structural defects.
Look at the throat and ear.
Investigation - Epistaxis Ddx
Investigation:
FBE, clotting/coagulation profile, LFTs, CT-scan
Management - Epistaxis Ddx
Condition -
- You have a condition which we call medically as epistaxis or nosebleed. Bleeding from the nose can occur in tiny vessels that are just under the thin surface of the anterior or posterior part of the nose. The nasal lining has extensive blood vessels which help to warm the air that enters the nose and this tissue is fragile and thin, and if damaged because of any condition, can result to a nosebleed. The bleeding occurs usually quite suddenly, and most commonly from one nostril. It may occur once or twice or many times over weeks.
Common
Cause
- trauma
- picking of nose
- hypertension (primary or secondary)
- colds/ URTI
- medication
Clinical feature
- bleeding in one nostril
Complication
It is generally not a serious condition, but sometimes, the bleed can occur from the back of the nose which can be a serious problem.
Management - Epistaxis Ddx
- Don’t blow the nose for the next 12 hours. Do not lie down or keep your head elevated to 30-45 degrees for several hours. If you sneeze, use an open mouth. Do not put anything solid in your nose.
- If it is very dry and hot, use humidifier at night to prevent cracking or use saline drops/spray 2-3x a day. Drink plenty of fluids and do not pick your nose or clip your nose to avoid injury.
- Avoid smoking. Do not strain or bend down to lift anything heavy.
- Stop ASA and switch to another drug such as panadol and address hypertension. Monitor and control blood pressure.
- If it happens then do tamponade: Sit down and put your head forward then firmly pinch the soft part of the nose between thumb and fingers for 5 minutes and put ice pack on nasal bridge. If bleeding does not stop then pinch it for 10 minutes. But if bleeding continues for more than 20 minutes then come back immediately to the ED.
- Anterior: may cauterize with tricholoroacetic acid or silver nitrate OR packing
o Contraindication for silver nitrate: do not do it on both sides à risk of perforation of nasal septum
o Nasal packing: Merocel (surgical sponge) nasal tampon – up to 5 days; or gauze - Posterior: may do nasal packing; straightforward reason for admission à admit, start IV line and NSS and stabilize
- Contraindications: fracture of basal skull or septal hematoma
- Cover with antiobiotics (flucloxacillin)
- For persistent epistaxis: bacitracin (10 days), vaseline/rectinol ointment, or nasalate nasal cream (7-10 days)
- Red flags: If it lasts more than 20 minutes or if the blood is flowing back then go to ED.
History - Renal Artery Stenosis
- History:
- Is my patient hemodynamically stable?
- HOPI -
- When did it start?
- Is it coming from one or both?
- on and off or continuous?
- How long did it last?
- Did it have any blood clots?
- Did it stop spontaneously?
- Is it the first episode?
- Do you notice that the blood is trickling or going down the throat?
- ASSOCIATED SYMPTOMS
- Any nausea/vomiting?
- Any headache?
- Any fever?
- DOB
- Chest Pain
- Swelling on back or leg
- Change in color of urine
- Body weakness
- Numbness or tingling sensation
DDX/RISK FACTORS
- Any trauma to the nose?
- Did it come after picking of the nose or sneezing?
- Hot Weather?
- Any recent URTI?
- Do you bruise easily?
- Do you have any change in the color of stool or urine?
- Medications - ASA, Nasal sprays
SECONDARY HYPERTENSION
- Any lumps or bumps in the tummy - Renal artery stenosis, Polycystic disease
- Change in color of urine - Glomerulonephritis
- Body weakness , Visit the loo more often especially at night - Primary aldosteronism
- Leg pain when you walk a certain distance - Coarctation of aorta
- Headache, sweating, palpitations - Phaeochromocytoma
- PMHx: Do you have any known medical condntions like heart disease, hypertension, DM, High, lipids, Kidney or liver disease?
- Any recent surgery?
- Medications? Allergies?
- Any bleeding disorders?
- How are your periods?
- Any FHx of any bleeding disorders?
- SADMA?
Physical Examination - Renal Artery Stenosis
Physical examination
- General appearance and BMI - PICCLED
- Vital signs (check BP in different position) Sitting and standing, both arms
- ENT: funduscopic examination - hemorrhages, AV nipping, papilledema
- Neck - Carotid bruit, JVP
- Heart - s1 s2, rate and rhythm, murmur, added sound.
- Respiratory system - air entry equal, any added sound ( wheeze or crackles)
- Abdomen: bruits (left renal bruit), masses
- Femoral - radiofemoral delay
Office test: urine dipstick (normal), ECG, BSL normal
Investigation - Renal Artery Stenosis
Investigation
- FBE, inflammatory markers, UCE, Serum K and Na, LFTs, FBS, Lipid profile
- ECG 12-leads, Echo
- Carotid and and femoral UTZ
- Kidney doppler Utz
- 24 hour urinary catecholamines,
- spiral CT scan (calcification of aorta, high-grade stenosis of left renal artery, less marked stenosis on right, both kidneys normal in size)
Management - Renal Artery Stenosis
Management
- Uncontrolled blood pressure
- Bilateral renal artery stenosis
- Epistaxis
- Dyslipidemia
- Overweight
- Consider cardiology review, echocardiogram, lifestyle modification, weight reduction, exercise, diet, salt
