Epistaxis

Will Davies 2nd April 2009

Active Epistaxis

Airway safe?Breathing not compromised?

Circulation adequate?

Conservative management measures;Spray with oxymetalozine

Nasal compressionHead forward

Inspect nostrils to identify bleeding source

Address anterior bleeding sourcesConsider:Cautery

Anterior nasal packingBilateral packing

Posterior packingNasal balloon catheter

Surgical referral

NO

YES

Bleeding Persists

Bleeding Stops

Bleeding Stops

Bleeding Stops

Bleeding Persists

Bleeding Persists

Adult Epistaxis Treatment Algorithm EMCore HK 2014

Resuscitate as needed

Observe for rebleed (no clear recommendation

of time frame)Consider packing

Follow up with ENT within 48hrs

Antibiotics if packed (no evidence)

Admit to ENT inpatient unit

Removal of packing 48-72hrs

EPistaxis, the three Ps

•  Pressure-direct pressure ?control of blood pressure

•  Pledgets/ Packing •  Platelet activators

Epidemiology

•  Bimodal distribution; – <10yrs old

•  Nose picking, foreign bodies, allergic rhinitis, ITP, Osler-Weber-Rendu disease

– >50yrs old •  Hypertension, anticoagulation/antiplatelet, liver disease,

CRF – Young adult, be alert to cocaine abuse

•  90% will stop with interventions available in ED

Anatomy

•  90% occur within the vascular watershed area of the nasal septum known as Kiesselbach's plexus (Little’s area), these are anterior bleeds

•  Posterior epistaxis arises most commonly from the posterolateral branches of the sphenopalatine artery but may also arise from the internal carotid artery!

First Aid- Pressure

•  Will settle most anterior bleeds: – Patient blows their nose to remove blood and clots – Patient pinches the alae tightly against the septum

and holds continuously for 15-20 minutes •  Ice packs on the back of the neck, supposedly

to cause vasoconstriction, do not work

Emergency Department-Pressure

•  The addition of oxymetazoline, co-phenylcaine or 1:1000 adrenaline improves the efficacy of alae pressure

•  Blood pressure control: there is association between hypertension and epistaxis, but control of BP does not help epistaxis control. Chronic hypertension caused friability of end anastomotic vessels and thus increased bleeding

Emergency Department-Pledgets •  The addition of oxymetazoline, co-phenylcaine or

1:1000 adrenaline improves the efficacy of alae pressure

•  Pledgets are the ideal vehicle for the drug when direct pressure has failed after 20 mins

•  This should stop up to 65% of patient who make it to ED from bleeding

Emergency Department-Cautery •  Most appropriate for anterior bleeds of low volume

originating from Little’s area. •  Tips:

–  Never attempt under the age of four years, as it is unlikely that a child will co-operate.

–  Allow time for anaesthesia to work –  Have the patient lie down –  Have a good headlight –  Silver nitrate sticks may not require moistening with water.

Excessive moistening may lead to silver nitrate solution running and staining the nares

–  Give instructions about: •  Give petroleum gel b.d. for one week •  No nose blowing for one week •  No nose picking •  Avoid hot drinks for 24 hours

Emergency Department Anterior Packing

•  Most anterior bleeds should have settled by now •  Anterior packing is required when the bleeding

fails to stop with vasoconstrictors and cautery •  Options include traditional nasal packing, a

prefabricated nasal sponge, an epistaxis balloon, or absorbable materials.

•  Nasal tampons that are moistened, gel-coated, with an inflatable balloon are less painful and show equal efficacy when compared with dry nasal tampon

Emergency Department-Anterior Packing

Traditional Packing Gauze

•  Grasp the gauze with a bayonet forceps, leaving an approximately 10 cm (4 inches) tail

•  Gingerly advance the gauze as far as possible into the nasal cavity without touching the walls of the nasopharynx

•  Grasp another 8 to 10 cm of gauze and advance it atop the prior layer. •  Repeat this process until the nose is tightly packed

Emergency Department-Anterior Packing: Merocel

•  Position the patient properly and pretreat with a topical anaesthetic (2% lignocaine) and topical vasoconstrictor

•  Insert the tampon by sliding it directly along the floor of the nasal cavity until nearly the entire tampon lies within the nasal cavity.

•  Large nares can be packed with two tampons (be sure to leave the tips of both exposed for removal); small nares can be packed with a paediatric tampon or an adult tampon trimmed with scissors.

•  Expand the tampon by infusing approximately 10 mL of saline

Emergency Department-Anterior Packing:Rapid Rhino

•  Position the patient properly and pretreat with a topical anaesthetic (2% lignocaine) and topical vasoconstrictor

•  Soak the catheter in sterile water for 30 seconds. Do NOT use saline and do NOT apply lubricants or topical antibiotics, which impairs the carboxymethylated cellulose

Emergency Department-Anterior Packing: Rapid Rhino

•  Insert the catheter by sliding it along the floor of the nasal cavity until the plastic proximal fabric ring lies within the nares

Emergency Department-Anterior Packing: Rapid Rhino

•  Inflate the catheter with air only using a 20 mL syringe; stop inflating when the pilot cuff is round and firm. The appropriate amount of air varies with the size of the nasal cavity.

•  After 10 to 15 minutes, reassess the pilot cuff. Add air if it is no longer round and firm. Tape the pilot cuff to the patient's cheek

Emergency Department-Anterior Packing

Techniques Compared

•  There appears to be no difference in efficacy between the techniques when it comes to stopping epistaxis

•  The Rapid Rhino seems to win out when it comes to ease of insertion and removal and patient comfort

Emergency Department-Anterior Packing

Role of Post Packing Antibiotics •  Many ENT specialists advocate augmentin or

third gen cephalosporin •  No evidence for this in prevention of toxic

shock syndrome •  Theoretically will lead to more harm than good

due to allergic reactions and bacterial resistance

•  Most people practice defensive medicine, I leave it to you

Emergency Department-Posterior Packing: Indications

•  Failure of anterior packing •  Reliable or high suspicion of posterior

bleeding (patient spitting out blood, older patient with atherosclerosis, no visible anterior bleeding site)

•  Patient with bleeding diathesis (hereditary haemorrhagic telangiectasia, haemophilia, anticoagulation, antiplatelet therapy)

Emergency Department-Posterior Packing: Contraindications

•  Posterior nasal packing should not be performed in the presence of facial trauma that may include nasal bone and cribriform plate fractures

•  If the patient is in shock, has altered mental status, or is otherwise not protecting the airway, the airway must be controlled before any nasal packing is attempted

Emergency Department-Posterior Packing

Double Balloon Catheter Technique •  Position the patient and pretreat with a topical

anaesthetic (2% lignocaine) and topical vasoconstrictor

•  Advance the catheter along the floor of the nasal cavity until the retention ring reaches the entrance of the naris.

•  Inflate the posterior balloon with 10 mL of sterile saline.

•  Retract the catheter gently until it lodges against the posterior choana in the nasopharynx.

•  Once the posterior balloon is seated, inflate the anterior balloon with 30 mL of sterile saline. If the patient experiences severe pain or deviation of the nasal septum or soft palate, gradually deflate the anterior balloon until the pain or deviation resolve.

•  Pad and protect the alae and naris entrance as necessary to prevent excessive pressure.

Emergency Department-Posterior Packing

Foley Catheter Technique •  Before insertion, coat the catheter with a suitable, petroleum-

free lubricant and trim the tip of the catheter to minimize irritation of the posterior structures.

•  Advance the catheter along the floor of the nose until it is visible in the posterior oropharynx.

•  Partially fill the balloon with 5 to 7 mL of sterile saline. •  Retract the catheter gently until it lodges against the posterior

choana in the nasopharynx. •  Complete the filling of the balloon by adding another 5 mL of

sterile saline. Pain or distention of the soft palate suggests overfilling.

•  Clamp the catheter in place with an umbilical clamp or small c-clamp, as from a nasogastric tube. Place padding between the clamp and the alae to prevent excessive pressure, which otherwise can lead to necrosis

Emergency Department-Posterior Packing

Foley Catheter Technique

Emergency Department-Posterior Packing: Pitfalls

Avoid in Craniofacial Trauma

Intracranial Foley catheter - Inadvertent malpositioning in setting of severe craniofacial trauma. Sakari et al. Indian Journal of Neurosurgery. 2012, vol 1, 2 185-186

Thank You