Epistaxis: Difference between revisions
Ostermayer (talk | contribs) (→Source) |
Kurtucla05 (talk | contribs) (updated rapid rhino technique) |
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*Only use if all of the above have failed | *Only use if all of the above have failed | ||
#Rapid Rhino | #Rapid Rhino | ||
##Soak balloon w/ water and insert along the floor of the nasal cavity | ##Soak balloon w/ water(NOT saline) and insert along the floor of the nasal cavity | ||
##Inflate slowly with air until the bleeding stops | ##Inflate slowly with air(NOT saline or water) until the bleeding stops | ||
#Merocel | #Merocel | ||
##Absorbent nasal tampon | ##Absorbent nasal tampon |
Revision as of 23:30, 5 September 2014
Background
- Types
- Anterior
- 90% of nosebleeds
- Occur in anterior septum (Kiesselbach plexus)
- Can visualize with anterior rhinoscopy
- Posterior
- 10% of nosebleeds
- Occur from nasopalatine branch of sphenopalatine artery
- Cannot visualize
- Anterior
- Risk factors
- Digital trauma
- Rhinosinusitis
- Anticoagulant/antiplatelet use
- Trauma
- Neoplasia
- Hypertension (does not cause bleeding but prolongs existing bleeding)
Diagnosis
- Anterior versus posterior hemorrhage
- Assume posterior if measures to control anterior bleeding fail
- Posterior bleeding associated with:
- Coagulopathy
- Significant hemorrhage visible in posterior nasopharynx
- Hemorrhage from bilateral nares
- Epistaxis uncontrolled w/ either anterior rhinoscopy or anterior pack
Treatment
Direct Nasal Pressure
- Have pt blow nose to expel clots or suction nose
- Instill topical vasoconstrictor (oxymetazoline or phenylephrine)
- Have pt apply direct pressure to nose
- Pt leans forward w/ nares pinched between thumb and middle finger for 10-15min
Chemical Cauterization
- Consider if two attempts at direct pressure fail
- Only perform if the bleeding vessel is adequately visualized
- Anesthetize w/ cotton pledgets soaked in 1:1 mix of 0.05% oxymetazoline:4% lidocaine
- Once achieve bloodless field, place silver nitrate just proximal to bleeding source
- Leave on for only a few siconds
Thrombogenic Foams
- Apply Gelfoam or Surgicel on visualized bleeding mucosa
- Bioabsorbable so removal/abx not needed
Anterior Nasal Packing
- Only use if all of the above have failed
- Rapid Rhino
- Soak balloon w/ water(NOT saline) and insert along the floor of the nasal cavity
- Inflate slowly with air(NOT saline or water) until the bleeding stops
- Merocel
- Absorbent nasal tampon
- Coat tampon w/ water-soluble abx ointment and insert along floor of nasal cavity
- If tampon has not expanded w/in 30s of placement, irrigate it in place w/ NS
- Traditional Packing
- Apply ribbon gauze in accordion-like manner
Posterior Nasal Packing
- Only consider if all of the above have failed
- Associated w/ higher complication rates (pressure necrosis, infection, hypoxia)
- Temporizing measure while awaiting ENT support
- Consider nasal block as posterior packing is often very uncomfortable
- All posterior packing should be accompanied by anterior packing
- Rapid Rhino
- Inflate posterior balloon
- Foley catheter w/ 30-cc balloon
- Lubricate w/ topical antibiotic
- Advance transnasally until visualized in posterior oropharynx
- Inflate balloon w/ 7cc of saline; retract 2-3cm until lodged in post nasopharynx
- Inflate w/ additional 5-7cc of saline to complete the pack
Complications
Disposition
- Anterior Epistaxis
- Discharge after 1hr of observation
- Pts w/ therapeutic warfarin levels may continue medication
- Discontinue NSAIDs for 3-4d
- Precribe amoxicillin-clavulanate if anterior packing was placed
- ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
- Posterior Epistaxis
- Admission is strongly advised
Source
- Tintinalli
- Rosen's