Epistaxis Flashcards
List the 6 Sx related to conditions of the nose.
- Block: congestion vs total obstruction; uni vs bi
- Rhinorrhoea (runny nose)
- Rxn to irritation: itching, sneezing, pain
- Change in smell: decreased/absent, foul
- Facial pressure/pain
- Epistaxis
What are the two classifications of epistaxis?
- Anterior epistaxis
2. Posterior epistaxis
Most cases of epistaxis across all age groups are from ___ origin
80% are from anterior origin (Little’s area) from specifically the Kiesselbach’s plexus
Characteristics of anterior epistaxis
- Originates from front of nose
- Low volume
- Unilateral in origin (start from one side but may come out both sides)
- Do not tend to result in presentation to emergency care
Clinical presentation of anterior epistaxis
- Nosebleed that is unilateral and low volume of blood
- High BP (anxiety)
Clinical presentation of posterior epistaxis
- Nosebleed where it explodes bilaterally through nostrils and spitting copious amount of blood; sudden
- Tachycardic
- Hypotension in severe epistaxis
Posterior epistaxis most commonly occurs in _____
Elderly
Why are posterior epistaxis most common in elderly?
- Weakened blood vessels
- Arteriolosclerosis
- Elderly vascular paths
Causes of epistaxis
a. Idiopathic 90%
b. Local:
- Trauma
- Vascular causes
c. Systemic:
- anticoagulants
- coagulopathy
d. Hypertension
Explain how trauma can be a cause of epistaxis
a. Micro-mucosal trauma: picking nose, colds, dry air
b. Macro-mucosal trauma: hitting, MVA
Explain how vascular factors can be a cause of epistaxis
a. abnormal vessels (cancer)
b. increased blood flow to nose (i.e. not something wrong with blood)
c. infection
d. coughs + cold
e. hot days
f. increased periods of congestion: night time, changes with hormones
Explain how anticoagulants can be a cause of epistaxis
- Secondary to drugs: aspirin, warfarin, alcohol, sildanifil, NSAIDs, clexane, NOACs
Explain how coagulopathies can be a cause of epistaxis
- Haemophilia
- von Willebrands disease
- Thrombocytopaenia
Explain how hypertension can be a cause of epistaxis
This is an indirect cause -> atherosclerosis -> nose bleeds. If BP suddenly rises it will not cause a nose bleed, but if you have a nose bleed whilst hypertensive it will bleed more profusely. It is a complication factor
DDx of epistaxis
Pseudoepistaxis must be rule out, as extranasal sites may stimulate epistaxis:
- Pulmonary haemoptysis
- Bleeding oesophageal varices
- Tumour (pharynx, larynx, trachea)
Ix of epistaxis
- Hb and Ht
- Platelet count
- Coagulation studies
- Cross match bloods
- Blood urea and nitrogen
Why would anaemia from epistaxis be normochromic and normocytic?
Hb is a concentration, therefore the of Hb per blood will remain the same. If we stop the bleeding and restore the volume, the pt will become anaemic that is normochromic and normocytic because normal RBC but in greater volume
How would we replace fluids?
Crystalloid rather than colloid, and then give them blood.
What we replace what the patients is losing (taking into account risk) - if losing fluid replace with fluid, if losing blood replace with blood
Px steps of the nose?
General Vital Signs System Specific - Anterior Rhinoscopy - Nasoendoscopy
- External view: is their gross deviation?
- Nasal obstruction: block each nostril separately + ‘sniff in’
- Tilt tip
- Look in - thudicum speculum and pen torch
What is the main Q asked before administering Rx to a patient?
Is the patient stable?
Are they at risk of becoming unstable?
(shock, tachycardic)
What is the ABC of triage assessment and how does it relate to epistaxis?
Airway - can be compromised with nose bleed
Breathing - can be compromised with nose bleed
Circulation - what if something has changed? Always cycle back to A - whenever something changes in a resuscitation.
What patient factors indicate a patient is at risk of becoming unstable?
- Coagulopathy + anti-coagulation
- Dehydrated - neglected and discovered by relative not sure how long they have been bleeding for
- Extremes of age: the elderly and little children - less reserve will tolerate a low Hb and low volume poorly
- The amount of blood and it not stopping - not slowing down - patient will meet a point where they can no longer compensate. Ongoing volume loss.
What are the classes of haemorrhagic shock?
INSERT TABLE
Non-pharmalogical Rx of epistaxis
- Pinching lower cartilaginous part of nose for 10 mins; lean forward (do not lean back); cold compression on bridge of nose to stimulate vasoconstriction
- avoid triggers: trauma, diet, exercise, sleep
- saline rinsing, moisterisers to reduce dryness
Acute Rx of epistaxis
- Stimulate vasoconstriction: topical lignocaine with adrenaline
- Cauterization
- Nasal packing (nasal gauze, packs up and tamponades the bleed)
Chronic Rx of epistaxis
- Endoscopic cauterization
- Open surgery, radiation
What is the ladder of intervention in epistaxis? ** important
- First Aid: local pressure (squeeze low and firm), calm down + sit down
- Modify risk factors: do not pick nose + air dryness
Reassure the patient. - Modify triggers
What if still bleeding? - Local pressure
- Get the blood pressure down - get patient to calm down and focus on their breathing. We can use pharmacological agents; calcium channel blockers, GTN not good as it is a vasodilator, give them a sedative (benzo or morphine) BUT drowsiness may not protect the airway = titrate dose.
- Vasoconstrictors
a. Adrenaline = adrenergic agonist
b. Cocaine = NA re uptake inhibition
c. Phenylephrine + oxymetazoline: agonist alpha adrenergic receptors
We can put them topically in combination. The advantage of cocaine is that it also numbs the nose - Cautery
- Anterior packing
What is von-Willebrands disease?
Binds platelets to each other, and to the damaged endothelial wall
Co-factor for Factor VIII.
What are the typical features of coagulopathy?
INSERT TABLE
List all the steps of managing a patient who presents to ED with epistaxis.
Conservative:
a. ask pt to pinch nares (or use two tongue depressors taped together if patient is unable to), lean forward
b. place ice pack on neck
c. place gauze ball with lignocaine solution (vasoconstriction)
Get Obvs - nb if HTN never treat, as this HTN is due to anxiety therefore treatment is treating the epistaxis
Rx:
a. Nasal pack: place nose tampon “rapid rhino” (soak in sterile water first - haemostatic agents activated). Insert with nose floor parallel to floor (head upright, normal). Can use head lamp to visualise. Can leave in for 24 hours.
If double packing (both nostrils) admit and observe as patients can have apnoea.
b. Prophylactic cephalexin (to prevent S. aureus TSS).
c. Consider cauterization
