SPC- Epistaxis Flashcards
Demonstrate an understanding of the causes of epistaxis and demonstrate competence in the management of uncomplicated cases
How can nosebleeds be classified?
According to their location of bleeding- anterior or posterior
Where do the majority of nosebleeds come from?
The majority of nose bleeds are anterior.
This comes from an Kiesselbach’s Plexus or little’s area which is found on the anterior nasal septum.
What is significance of Kiesselbach’s plexus/Little’s area?
It is the site where the majority of nosebleeds come from, this is in the anterior nasal septum.
What arteries anastomose to form Little’s area?
Anterior ethmoidal
Sphenopalatine
Facial arteries
Do the majority of anterior nosebleeds present unilaterally or bilaterally?
Majority present unilaterally
What are some causes of nose bleed?
Trauma
Idiopathic
Foreign body
Inflammation/Infection- e.g. Allergic Rhinitis, Vasculitic processes
Bleeding from nasal polyps
Neoplastic lesions causing bleeding (very angiogenic)
Drug- Nasal decongestants, anti-coagulants, anti-platelets, cocaine
Coagulopathies
What is the very initial management of epistaxis? i.e what is the initial protocol for managing them
Apply personal protective equipment
Treat as a medical emergency with an ABCDE approach
(bleeding could be major haemorrhage or there could be airway obstruction following trauma)
Check for patent airway, support respiration, if hypotensive fluids
What key questions would you ask about when assessing a patient with epistaxis?
Onset How long? How much? Recent trauma Taking any anticoagulants/antiplatelets PMH if important
What should you quickly examine when someone presents with nose bleed?
Attempt to visualise inside both nostrils
Exame the back of the mouth/oropharynx for any posterior bleedings (this is more difficult to manage and may need to quickly escalate)
If following trauma examine the surrounding area- e.g. are there any signs of orbital floor fracture
What is the initial conservative management for epistaxis?
How long should this be done for?
Ask patient to pinch the fleshy part of the nose whilst sitting upright and leaning forward
(This means they should breathe through their mouth)
Apply an ice pack to the bridge of the nose
Attempt this for 10-15 minutes.
After failure of initial conservative management for epistaxis what should be done?
Adrenaline application
(Soak a cotton wool ball in 1:200,000 adrenaline solution and apply this to the bleeding for 2 minutes using some forceps, reassess to see if stopped bleeding after 2 minutes)
Cautery (using silver nitrate which is applied lightly for 3-10 seconds until a grey/white colour develops)
What should be given after cautery has been carried out?
Naseptin cream- Chlorhexidine and neomycin
What is naseptin cream when is it used?
Naseptin cream is a cream that contains chlorhexidine and neomycin. It is a topical antiseptic cream that is applied to the nostrils QDS for 10 days
When is naseptin cream contraindicated?
Peanut allergy
What should be given before cautery is attempted?
Topical anaesthetic with a vasoconstrictor nasal spray should be used. E.g. Lidocaine with phenylephrine (co-phenylcaine). Wait 3-4 minutes before this takes effect.
Cautery can then be attempted with silver nitrate which is applied for 3-10 seconds- till the area turns grey/white.
Application of adrenaline and silver nitrate cautery requires visualisation of the bleeding point, what should be done if the bleeding is not visible and is continuing?
Refer to ENT
If a re-beed occurs after adrenaline application/silver nitrate cautery what can be done?
Nasal packing may be used
What is used for anterior nasal packing?
Rapid rhino, merocele or BIPP gauze nasal packing. Following instructions of these individually.
Rapid Rhino- wet pack before insertion
Merocele- string hands out and it is inserted, expands to fill cavity.
BIPP-Gauze- Forceps are used to pack the nose
How should packing be inserted?
Horizontally- so they actually go into the nasal cavity. This is parallel to the hard palate.
How long should nasal packing be inserted for?
24 hours and then re-assess bleeding state.
What can be done to pack a posterior nasal bleed?
A foley catheter (urinary catheter) can be inserted into the nasal cavity and used to obstruct the choana. Packing can be inserted. Posterior bleeds can be much larger and this requires ENT.
What might be done for very severe posterior nasal bleeds?
The bleeding needs to be stopped.
Arterial ligation- e.g. of the sphenopalatine artery
Interventional radiology to embolize the bleeding artery
What should you advise patients after successful treatment for epistaxis?
Avoid activities that could increase the risk of re-bleeding. e.g. heavy lifting, strenuous exercise, picking the nose, putting anything up the nose. Blowing the nose.
