EPISTAXIS Flashcards
MANAGEMENT
INITIAL MANAGEMENT
- Position patient upright in sniffing position
- Blow out clots from nose
- Apply pressure against the septum in the lower 1/3 of the nose for 15 min
- Consider adjunct intraoral ice
- Physical Exam if Hemostasis Achieved
VASOCONSTRICTION / ANESTHETIZE
If refractory to pressure
- INSERT COTTON PLEGET SOAKED IN:
VASOCONSTRICTOR:
Oxymetazoline 0.05%
OR
Phenylephrine 0.5%
OR
Epinephrine 1 mg / ml
OR
cocaine 4%
ANESTHETIC:
Lidocaine 1%-4% solution
- REMOVE AFTER AFTER 10-15 MIN
- Physical Exam if Hemostasis Achieved
CHEMICAL CAUTERIZATION
If refractory to vasoconsriction / anesthetization
- Cauterize with silver nitrate in 4 quadrants around bleed.
- Hold for 5-10 secs.
- Never cauterize both sides of septum.
- Do not repeat until 4-6 weeks after.
- Physical Exam if Hemostasis Achieved
ANTERIOR NASAL PACKING
If refractory to cauterization
MEROCEL NASAL TAMPON:
1. Coat with bacitracin or mupirocin.
2. Insert along floor of nasal cavity.
3. Irrigate with water.+ Tranexamic Acid. 500 mg TXA applied to topical foam or anterior nasal packing.
RAPID RHINO:
Anterior epistaxis balloons soaked with water.
Inflate slowly until bleeding stops.
POSTERIOR NASAL PACKING
- Posterior Nasal Balloon
There are 2 ports - Foley Catheter
Insert via nose until visible in the posterior oropharynx
Inflate until baloon seen in OP
Anterior traction until posterior vessels tamponade
Secure to face - KEFLEX
500 qid
INVESTIGATIONS
Routinely not indicated
CBC (HBG, platlets)
Lytes
Creat
LFTs
INR/PTT
DISPOSITION: DISCHARGE
Discharge after 1 hr observation
Do not to blow their nose for 7-10 days
Return to ER or Primary Care for removal within 24-48 hrs.
Irrigate prior to removal.
Discontinue NSAIDs 3-4 days
DOCUMENTATION
HISTORY
- HPI
Laterality
Duration - ASK ABOUT SEVERE BLEEDING
Estimated quantity of blood
Melena
Hematemesis
Pre Syncope
Chest Pain
Dyspnea - ASK ABOUT TRIGGERS:
Trauma
Foreign Body
Drug use
URTI / Rhinosinusitis
Drying of nasal mucosa / change in weather - ASK ABOUT RELEVANT PMHx
Prior Epistaxis
Bleeding disorders
HTN
Liver dz
Kidney dz
Cardiopulmonary Disease
Vascular Disorders
COPD on home o2
OSA on CPAP
Nasal or sinus surgery
Nasal malignancies - MEDS:
Anticoagulation or antiplatelet agents
Intranasal medication (intranasal steroid sprays)x` - SOCIAL:
intranasal drug use (cocaine). Cigarette Smoke
EtOH Use
PHYSICAL EXAM
1. BP:
HTN vs. HoTN
- MATERIALS
Lamp, Tongue Blade, Suction, PPE, Nasal Speculum - IDENTIFY LATERALITY
- IDENTIFY POSTERIOR BLEED
Bilateral Bleeding
Bleeding Not resolved with pressure
Blood in Posterior Oropharynx
Suction OP while apply pressure to nose in sniffing position if equivocal - SPECULUM EXAM
Once hemostasis is achived
Examin nose with nasal speculum with bright head lamp.
Open vertically i.e. the SAGITTAL plan
DDx
Local
-Trauma (picking, trauma to face)
-Foreign body
-Smoking
-Blood thinners
-Illicit drugs
-Sinusitis
-Neoplasm
-Septal deviation
-Vascular malformation
Systemic
-Hemophilia
-Leukemia
-Liver Disease
-Platelet dysfunction
-Thrombocytopenic
-OSA/CPAP
-COPD/Home O2
Environmental
-Humidity
-Allergens
-Home O2
