epistaxis Flashcards
what is epistaxis?
nose bleed
what are the types?
anterior + posterior
split anatomically
where does anterior epistaxis come from?
often has a visible source of bleeding and usually occurs due to an insult to the network of capillaries that form Kiesselbach’s plexus.
where does posterior epistaxis come from?
Posterior haemorrhages, on the other hand, tend to be more profuse and originate from deeper structures
what are causes of epistaxis?
nose picking
nose blowing
trauma to the nose
insertion of foreign bodies
immune thrombocytopenia
Waldenstrom’s macroglobulinaemia
juvenile angiofibroma
cocaine use
hereditary haemorrhagic telangiectasia
granulomatosis with polyangiitis
why does cocaine cause epistaxis?
the nasal septum may look abraded or atrophied, inquire about drug use. This is because inhaled cocaine
cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.
what is the mx - first aid + haemodynamically stable?
If the patient is haemodynamically stable, bleeding can be controlled with first aid measures. This involves:
Asking the patient to sit with their torso forward and their mouth open
avoid lying down unless they feel faint
his decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth
it also reduces the risk of aspirating blood
Pinch the cartilaginous (soft) area of the nose firmly
this should be done for at least 20 minutes
also ask the patient to breathe through their mouth.
what is mx after first aid?
consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis
self-care advice involves reducing the risk of re-bleeding
patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks should be avoided
what do you need to be cautious about its naseptin?
what is alternative
cautions to this include patients that have peanut, soy or neomycin allergies
Mupirocin is a viable alternative
who needs admission
admission and follow up care may be considered in patients under if
a comorbidity (e.g. coronary artery disease, or severe hypertension) is present, an underlying cause is suspected
they are aged under 2 years (as underlying causes such as haemophilia or leukaemia are more likely in this age group)
what do you do if bleeding does not stop after 10-15 minutes of continuous pressure on the nose
cautery should be used initially if the source of the bleed is visible and cautery is tolerated
packing may be used if cautery is not viable or the bleeding point cannot be visualised
how does cautery work?
ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume.
use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect
identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.
dab the area clean with a cotton bud and apply Naseptin or Muciprocin
how does packing work?
anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes
pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions
pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack.
examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel.
patients should be admitted to hospital for observation and review, and to ENT if available
what is mx for haemodynamically unstable pt?
control bleeding with first aid measures in the interim
patients with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital.
what do you do if all emergency mx failed?
may require sphenopalatine ligation in theatre
