Epitaxis Flashcards
What are the two forms of epitaxis?
- Anterior bleeds
- Posterior bleeds
Where is the source of anterior bleeds?
- a visible source of bleeding
- occurs due to an insult to the network of capillaries that form Kiesselbach’s plexus
What is the source of posterior bleeds?
- Tend to be more profuse
- originate from deeper structures
What are the risk factors for posterior bleeds?
- older patients
- Higher risk of aspiration
- Higher risk of airway compromise.
What are the benign causes of epitaxis?
- nose picking
- nose blowing
- trauma to the nose
- insertion of foreign bodies
What are more serious causes of epitaxis? (4)
- bleeding disorders
immune thrombocytopenia - Juvenile angiofibroma
benign tumour that is highly vascularised - Granulomatosis with polyangiitis
- Cocaine use
What is juvenile angiofibroma and who is it normally seen in?
- benign tumour that is highly vascularised
- adolescent males
What is the pathophysiology of cocaine use on the nose?
- Atrophy of the nasal neptum due to inhalaed cocaine
- cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.
What is the management of epitaxis in a haemodynamically stable patient?
- Asking the patient to sit with their torso forward and their mouth open
- Pinch the cartilaginous (soft) area of the nose firmly
* Done for min 20 minutes
* Breathe through the mouth
Why is it suggested to sit with torso forward and nose open?
- 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
What is the management following first aid measures? (2)
- opical antiseptic such as Naseptin (chlorhexidine and neomycin)
- reduce crusting and the risk of vestibulitis
When should Naseptin be used in caution and what is an alternative? (2)
- cautions to this include patients that have peanut, soy or neomycin allergies
- Mupirocin is a viable alternative
What self care advice should be given to prevent rebleeding? (4)
Avoid;
- blowing or picking the nose
- heavy lifting, exercise
- lying flat
- drinking alcohol or hot drinks should be avoided
When is cautery / packing indicated?
- If bleeding does not stop after 10-15 min of continous pressure on the nose
1. * Cautery is used if - Source of bleeding is visible
- Well tolerated
- Packing is used
- Bleeding point cant be visualised
- Cautery is not viable
- Packing is used
Explain the method of cautery for epitaxis (4)
- ask the patient to blow their nose in order to remove any clots
- Use topical local anaesthetic
- Apply silver nitrate stick for 3-10 seconds until area becomes grey white
* Only cauterise one side due to risk of perforation - Apply naseptin
Explain the method of packing for epitaxis (4)
- Anaesthetise with topical local anaesthetic spray
- Pack the patient’s nose while they are sitting with their head forward
- Examine the patient’s mouth and throat for any continuing bleeding, and 4. Consider packing the other nostril as this increases pressure on the septum and offending vessel.
- Admit to hospital for observation and review, and to ENT if available
What is the management of haemodynamically unstable patients?
1.Control bleeding with first aid measures in the interim
2.If unknown source or posterior bleed } admit
If all failed;
3. Sphenopalatine ligation in theatre
What is sphenopalatine ligation?
Ligation of the sphenopalatine artery which supplies the blood to the nasal cavity
- Frequent cause of nose bleeds
Nasal septal haematoma : Definition
complication of nasal trauma
development of a haematoma between the septal cartilage and the overlying perichondrium.
Nasal septal haematoma : Clinical features
may be precipitated by relatively minor trauma
1. Sensation of nasal obstruction
2. Pain and rhinorrhea
Examination : bilateral red swelling arising from the nasal septum
Nasal septal haematoma :Mx
If untreated irreversible septal necrosis may develop within 3-4 days - causing ‘saddle-nose’ deformity.
* surgical drainage
* intravenous antibiotics
