Epistaxis Flashcards
Anterior epistaxis usually occurs due to an insult to the network of capillaries that form…
Kiesselbach’s plexus
Posterior epistaxis originate from deeper structures e.g from…
Sphenopalatine artery
What causes epistaxis?
Local: Idiopathic Trauma Iatrogenic FB Inflammatory - rhinitis, polyps Neoplasia
Systemic:
HTN
Hereditary haemorrhagic telangiectasia
Thrombocytopenia, ITP, leukaemia, splenomegaly
In adolescent males a benign tumour (juvenile angiofibroma) can cause epistaxis because…
It is highly vascularised
If the nasal septum looks atrophied or abraded ask about…
Drug use
Inhaled cocaine is a powerful vasoconstrictor - repeated use may obliterate the septum
In the elderly, what can cause prolonged nasal bleeding?
Hereditary haemorrhagic telangiectasia
If patient is haemodynamically stable, bleeding can be controlled with first aid measures…
Sit with torso forward and mouth open
Pinch cartilaginous area (lower) of nose firmly, for 20 mins
Breath through mouth
Why should the patient sit forward with mouth open?
Decrease blood flow to nasopharynx and allows patient to spit out any blood in mouth.
Reduces risk of aspirating blood
If first aid measures successful, what can you consider using?
Topical antiseptic e.g Naseptin to reduce crusting and risk of vestibulitis (infection in nasal vestibule)
Caution if peanut, soy or neomycin allergy
If bleeding does not stop after first aid measures, what should be done next?
Consider cautery or packing
Cautery - source is visible and cautery tolerated (not well tolerated in young)
Packing- source not visible or cautery not viable
What process is involved in cautery?
Encourage patient to blow out nasal clots
Look inside and remove clots, gentle suction
Apply cotton ball soaked in adrenaline 1:200,000 (vasoconstriction) for 2 mins or use local anaesthetic spray e.g lidocaine and wait 3/4 mins to take effect
Identify bleeding point and apply silver nitrate for 3-10 sec (start from edge and work inwards) until it becomes grey/white
When using silver nitrate what safety measures should be followed?
Avoid touching areas that do not require treatment
Only cauterise one side of septum as risk of perforation
Avoid using if actively bleeding as will be washed away and may cause unwanted burns to lips etc
If you cannot see bleeding point, what should you do?
Anterior packing
Referral to ENT
What process is involved in packing?
Anaesthetise with topical local spray
Use anterior initially
Lubricate/soak pack as instructed, advance into nose parallel to hard palate, inflate if required and tape to face
If bleeding continues they posterior pack - variety available but a foley urinary catheter is effective
If serious posterior epistaxis occurs, what can be done?
Arterial ligation e.g of the sphenopalatine artery
Embolisation of internal maxillary or facial artery can be life saving, but stroke risk
