Epistaxis Management Workshop Rebecca Harvey, MD ENT for... · Epistaxis Workshop Evaluation Name...

Ninth Annual ENT for the PA-C | April 3 – 7, 2019| Orlando, FL

Epistaxis Management Workshop

Rebecca Harvey, MD

April 4, 2019Orlando, FL

Epistaxis Workshop

Clear Instruction

Live Demonstration

Hands-On Practice

Learn by doing

Control Anterior Epistaxis

Control Posterior Epistaxis


Introduction

There are multiple methods and techniques available to successfully complete all the topics presented in this workshop.

Your actual work experience may differ based on available equipment or your supervising physician’s preference.

The goal of this workshop is to correctly demonstrate the most common methods and give participants time for

hands-on training.


OBJECTIVES OF SESSION

• Discuss indications for and practice control of anterior epistaxis

• Discuss indications for and practice control of posterior epistaxis

• Utilize direct visualization via endoscopy to evaluate patient with nose bleed

• Recognize and properly address need for antibiotics and other care requirements while packing is in place



Anatomy Review


Anterior vs. PosteriorEpistaxis

Kiesselbach’s Plexus or Little’s Area is most common site of anterior nosebleeds.

Woodruff’s Plexus is most common site for posterior nose bleeds and may represent a lesion.

Sphenopalatine artery is generally the source of severe posterior nosebleeds.


Etiology of Epistaxis

Local

Trauma

Nose picking or blowing

Surgery

Dry air / Irritants

Topical medications (steroids)

Foreign body

Tumor

Systemic

Bleeding disorders

Hereditary hemorrhagic telangiectasia

Drugs (anticoagulants)

Hypertension



Control anterior epistaxis in office.

Apply direct manual pressure for at least 10 minutes

Mercado 2011 ©Mercado 2011 ©


Direct Manual Pressure

NO YESNO

Mercado 2011 ©Mercado 2011 © Mercado 2011 ©



Spray or apply topical anesthetic with decongestant.

Reapply direct manual pressure an additional 10 minutes.

Mercado 2011 ©



Once bleeding has subsided, identify site of nosebleed.

Mercado 2011 ©



Control bleeding with silver nitrate cauterization. (start from outside in)

Caution bilateral cauterization as may result in septal perforation.

Pearls: this can be more challenging in the patient who is actively bleeding and on anticoagulation –sometimes can make bleeding worse

Mercado 2011 ©



Lubricate naris with Vaseline® or bacitracin ointment.

Let sit for 10-15 minutes to ensure hemostasis is achieved.

Keep cotton in nares for at least 1 hour to prevent staining.

Avoid sneezing, forceful nose blowing, nose picking, etc.

Follow up 2 weeks as re-cauterization may be necessary.

Post chemical cauterization stain day 1

Mercado 2011 ©

Post chemical cauterization stain day 4

Mercado 2011 ©

Topical Hemostatic Agents

Anterior Nasal PackingNasal packing

• Absorbable gelfoam

• Vaseline gauze

• Nasal tampon

• Anterior packing

Mercado 2011 ©

Anterior Nasal Packing

Vaseline® gauze

• Inserted along floor of naris to form a tight seal.



Nasal tampon

• Expands in nasal cavity to form a tight seal.

• Do not allow packing to moisten until in position.

• Removal may cause re-bleeding.

Mercado 2011 ©

Mercado 2011 ©


Anterior Nasal Tampon

• Insert nasal tampon horizontally.

• Lubricate with bacitracin but DO NOT moisten!

• Secure ties to cheek.

Practice mannequins available to practice anterior nasal packing technique.

Mercado 2011 ©



Nasal Tampon

– Easy to insert and remove due to self-lubricating hydrocolloid fabric and ultra-low profile.

– Packing quickly conforms to nasal anatomy and provides gentle and even compression to areas of epistaxis.

Mercado 2011 ©


• Soak dressing to hydrate Gel Knit hydrocolloid fabric in sterile water for 30 seconds.

• Insert packing horizontally.

• Inflate balloon only with air.

• Tape pilot cuff to side of face.

Mercado 2011 ©

Mercado 2011 ©


Which of the following is correct?

A B




Anterior vs. PosteriorEpistaxis

Kiesselbach’s Plexus or Little’s Area is most common site of anterior nosebleeds.

Woodruff’s Plexus is most common site for posterior nose bleeds and may represent a lesion.

Sphenopalatine artery is generally the source of severe posterior nosebleeds.

Posterior tend to be more difficult to control andmay suggest an underlying etiology.

Distribution of the Sphenopalatine Artery


• Control Hypertension

• Identify Coagulopathy –Treat with FFP, transfusions, etc

– PT, PTT, INR

• Coumadin toxicity - Vitamin K

• Posterior Packing

• Endoscopic Cauterization

• Rule out anterior/posterior ethmoid source

• Arterial Embolization (Interventional Radiology)


Posterior Nasal Packing

• Topical anesthetic & decongestant

• Posterior nasal packing

– Foley catheter

– Double balloon device

1. Thoroughly soak in sterile water for 30 seconds.

2. Insert balloon packing into the patient’s nostril parallel to the septal floor, or following along the superior aspect of the hard palate, until the blue indicator ring is inside the opening of the nostril.

3. Using a 20 cc syringe, slowly inflate the posterior (green stripe) balloon first with air only inside the patient’s nose.

Posterior Packing

4. Inflate second balloon with air.

5. Allow the patient to sit for 15-20 minutes prior to discharge. Swelling in the nasal anatomy will reduce and the balloons may need to be inflated more to avoid movement of the device. Don’t forget prophylaxis antibiotics!

6. To remove packing, deflate balloons 24-72 hours later.

Posterior Packing

Steps:

1. Topicalize nose with lidocaine and oxymetazoline

2. Obtain Foley (10, 12, 14 French)

3. Lubricate and advance until balloon is seen in posterior oropharynx

4. Fill with 5-10 cc saline and apply traction until balloon sits firmly against posterior nasal choana

5. Secure pack with umbilical clamp or

C-clamp at nasal ala

1. Posterior packs can also be fashioned from red rubber catheters and gauze packs

2. Anterior packs such as Merocel® are sometimes also required if initial hemostasis is not obtained

Posterior Epistaxis – Foley Catheter Insertion

Posterior Epistaxis: additional options

• Epistat® nasal balloon

• Adjunctive packing – vaseline® gauze packing, merocel® packing

• Bilateral nasal packs

• Determine if need for procedural/surgical intervention exists

Anterior and Posterior Ethmoid Arteries: rare cause of posterior epistaxis

• Accounts for <10% of posterior bleeds• Branch of internal carotid artery –ophthalmic artery• Site is often high on the posterior septum• More common in setting of extensive Facial trauma, NOE fractures• Cannot be managed with embolization– result in blindness• Must be managed surgically with external ant/post ethmoid aa.

ligation


Juvenile Angiofibroma: another rare cause of bleeds

Juvenile angiofibroma – benign, highly vascular invasive mass that occurs in the posterior nasal cavity in less than 0.5% of head and neck tumors.

Almost always found in adolescent boys.

Presents with epistaxis and nasal congestion or both.

CT Scan w/contrast confirmed nasopharyngeal mass measuring 4.0 cm x 3.8 cm consistent with a juvenile angiofibroma.

Angiofibroma

Video Courtesy J. MercadoVideo


Monitoring after Posterior Pack Placement

• All patients requiring posterior pack should be admitted

• Bilateral pack placement requires continuous pulse oximetry, telemetry (risk of dysrhythmia, hypoxia)

• Monitor/trend CBC

• Reverse coagulopathy

Importance of Antibiotic Prophylaxis

• Several studies site a reduction in colonization by Staph species and decreased incidence of post-packing sinusitis and Toxic Shock when systemic antibiotic therapy is utilized

Additional Treatments

Arterial EmbolizationKoh E et al. AJR 2000;174:845-851

http://www.ajronline.org/content/174/3/845.full

Sphenopalatine ArteryLigation

External Anterior and Posterior Ethmoid Artery Ligation

Summary: Epistaxis Management

Direct Pressure

Chemical Cauterization

Nasal packingThermal

Cauterization

Embolization

Practice mannequins available to practice anterior and posterior nasal packing technique.

Mercado 2011 ©


LEARNING STATIONS

• Anterior epistaxis and silver nitrate cautery

• Simulation of electrocautery

• Placement of anterior nasal packs

• Placement of posterior nasal packs/foley

• High fidelity anatomic model to practice visualization and identification of anterior and posterior sites of epistaxis

Task: Control Anterior EpistaxisIndications: Anterior persistent nosebleed in office

1. Apply direct manual pressure for at least 10 minutes.

2. Spray or apply topical anesthetic with decongestant. Reapply direct manual pressure an additional 10 minutes

3. Once bleeding has subsided, identify site of nosebleed

4. Control bleeding with silver nitrate cauterization. (start from outside in)

5. Lubricate naris with Vaseline or bacitracin ointment. Keep cotton in for at least 1 hour to prevent staining.

6. Let sit for 10-15 minutes to ensure hemostasis is achieved.

• Avoid sneezing, forceful nose blowing, nose picking, etc. • Follow up 2 weeks as re-cauterization may be necessary.

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

Task: Control EpistaxisIndications: Persistent anterior or posterior nosebleed despite cauterization

1. Thoroughly soak in sterile water for 30 seconds.

2. Insert nasal pack into the patient’s nostril parallel to the septal floor, or following along the superior aspect of the hard palate, until the blue indicator ring is inside the opening of the nostril.

3. Using a 20 cc syringe, slowly inflate the posterior (green stripe) balloon first with air only inside the patient’s nose.

4. Inflate second balloon with air.

5. Allow the patient to sit for 15-20 minutes prior to discharge. Swelling in the nasal anatomy will reduce and the balloons may need to be inflated more to avoid movement of the device. Don’t forget prophy antibiotics!

6. To remove packing, deflate balloons 48-72 hours later.


Nosebleed trainers: Cautery and packing


High fidelity trainer

Utilize rigid scope to identify bleeding site

and pack under direct visualization

PM ExtraStationindirect laryn-

goscopyMIRROR

EXAMP

rojecto

rSp

eaker

ENTR

AN

CE

Station 1 rhino packs on table top models

Johnny Trauma modelPractice posterior

packing,

Station 2Video Tower;

suction;“Cautery”

stop bleeds on

epistaxis trainer

Station 3Video Tower;

suction;“Cautery”

stop bleeds on epistaxis

trainer ,

Station 5: Video Tower,

practice packing,

3D trainer with rigid scope


Reminder: complete your workshop cards and turn them in

at the end of this session.

• Score cards will be used for admission to workshops and

attendance.

• Credit will only be awarded for completed

score cards.

• Rotate and complete each station.

• Completion of workshop is NOT contingent on

pass/fail

Epistaxis Workshop Evaluation

Name Circle Session 1 2 Date 4/4/19

Scale: 1=NO or LOW, to 5=YES or most likely/most positive Scale 1-5

1. Were learning objectives met?

2. Was instruction free of commercial bias?

3. Was there adequate instruction before hands on practice?

4. Was there adequate supervision during testing?

5. Were training aids useful/realistic in learning desired skill?

6. How likely are you to perform these skills in the future?

7. Did this training improve your skills?

ATTENDEE NAME (print) _____________________________

ATTENDEE SIGNATURE:

Score cards will be used for admission to workshops and attendance. Credit will only be awarded for completed score cards.

Epistaxis Workshop Score CardRotate and complete each station. “Go/No Go” for internal use only.

Completion of workshop is NOT contingent on pass/fail.

Task Go No Go

1. Identify common source of anterior epistaxis.

2. Practice methods to stop anterior epistaxis on mannequin.

3. Identify a common source of posterior epistaxis.

4. Utilize rigid scope to find source of epistaxis on trainer model

5. Demonstrate proper placement of packing material.

Comments:

Proctor Name Proctor Signature

Date post:	20-Jul-2020
Category:	Documents
Upload:	others
View:	7 times
Download:	0 times

Epistaxis Management Workshop Rebecca Harvey, MD ENT for... · Epistaxis Workshop Evaluation Name...

Documents