3. epistaxis

5/25/2018 3. Epistaxis

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O l e h :SIGIT SASONGKO

DEPARTEMEN THTRUMKIT TK. II DUSTIRA CIMAHI

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RIWAYAT HIDUP SINGKAT

Nama : Sigit Sasongko, dr, MKes, SpTHT

Tempat/Tgl. lahir : Probolinggo, 7 Januari 1966

Pangkat : Letnan Kolonel CKM

Jabatan akademik : Lektor

Jabatan struktural : Ka. Lab/KSM I.K. THT FK Unjani/RS Dustira

Riwayat pendidikan :

S-1 FK Unair Surabaya, 1990

S-2 dan Sp-1 FK Unpad Bandung, 2003

Riwayat pekerjaan : Anggota PERHATI Jabar, 2006sekarang.

Ka. Lab/KSM I.K. THT FK Unjani/RS Dustira, 2007sekarang

Dosen LB PPDS I I.K. THT FK Unpad, 2008 - sekarang

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Anatomi Hidung dan SPN

Hidung Luar :Bentuk piramidBagian-bagian :

Puncak hidung (apex N)Dorsum nasiPangkal hidung (bridge)

KolumelaAla nasiNares anterior


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PerdarahanAtasR.Hd.: a.karotis interna a. oftalmikus

a ethmoid anterior dan posteriorBawahR Hd : cabang a maksilaris internaa sfenopalatinadan ujung a palatina mayor

DepanR.Hd.: cabang fasialisDepan septum: Plexus Kieselbach(Littles area)

Anastomosis dari : a. Ethmoid anterior

a. Sfenopalatina dana. Palatina mayora. Labialis superior

Letaknya superfisial, mudah cedera

Sumber epistaksis terbanyak


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A : a. meningeal anterior

B : a. etmoidal anterior

C : a. etmoidal posteriorD : a. nasal lat. posterior

E : a. spenopalatina

F : a. palatina mayor & minor

Arteri pada dinding lateral hidung


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A : a. etmoidal anterior

B : a. etmoidal posterior

C : a. septal nasal posteriorD : anastomosis dengan

a. palatina mayor

Arteri pada septum nasi


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ANATOMI VASKULARISASI HIDUNG

BERASAL DARI CABANG A. KAROTIS

INTERNA DAN A. KAROTIS EKSTERNA


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EpistaksisMungkin 90% dapat berhenti spontan (penekananhidung). Epistaksis berat perlu tindakan

Etiologi :

1. Sebab lokal :a. trauma:

Beringus keras, bersin keras, rudapaksa, iritasi gas

b. Infeksi hidung/sinus paranasalc. Neoplasma: hemangioma, karsinoma, angiofibromad. Kelainan kongenital

Oslers diseases (hereditary hemorrhargicteleangiectasis)


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2. Sebab-sebab sistemik epistaksis:

a. Penyakit kardiovaskularhipertensi, arteriosklerosis, nefritiskronik, sirosis Hp., sifilis, DM.

b. Kelainan darahtrombositopeni, hemofilia, leukemia

c. Infeksi:DHF, tifoid, morbili, influenza

d. Perubahan tekanan atmosfirCaisson diseases

e. Gangguan endokrin

kehamilan, menopause

Etiologi Epistaksis :


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Sumber Perdarahan epistaksis :

Dua sumber utama :1. Bagian anterior

Pleksus Kiesselbach

a. etmoidalis anteriorterbanyak dan tidak hebat

2. Bagian posteriora. sfenopalatinaa. etmoidalis posteriorLebih jarang, tetapi hebat


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Terapi Epistaksis:

Tiga prinsip :

1. Hentikan perdarahan

2.Cegah komplikasi

3.Cegah rekurensi


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PHYSICAL

EXAMINATION

General status

Local status

Determine :- Anterior or posterior

- Right or left cavum

nasi

- Duration of bleeding

- Quantity of blood loss


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MANAGEMENT

BASIC CARE OF HEMORRHAGE1. Vital signs

2. Hemoglobin and hematocrit

3. Fluid resuscitation & blood transfusion4. Central venous pressure

Uncommon, but the condition is life-threatening:

Exsanguinating epistaxis

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Predisposition factors :

severe midfacial trauma with maxillary artery

laceration, often associated with multisystem trauma.


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M N GEMENT1. Cauterization : Silver nitrate & electric

2. Nasal packinganterior, posterior or

both3. Ligation of arteries :

a. Ethmoid arteries, anterior & posterior

b. Internal maxillary & sphenopalatinearteries

c. External carotid arteries

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Anterior Nasal packing

Anterior nasal packing :

traditional ribbon gauze pack,

prefabricated expandable packs

intranasal balloons applied to an identified orunidentified bleeding site

mini packdirectly to the bleeding site

Procedure Technique

Local anesthesia : decreasing discomfort,

decrease the risk of apnea, bradycardia, andhypotension

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nterior Nasal packing

If technically possible, placinga single layer of absorbablematerialover the known

bleeding site first followedby the packing material mayprevent rebleeding afterpack removal

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TOOLS :

- Protective eyewear

-Cover gown and mask

-Head lamp and Light source

-Nasal speculum, tongue spatel

-Bayonet pinset

-Suction

-Packing

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TOOLS

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TOOLS

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nterior Nasal packing

The traditional anterior pack of petrolatum gauze (0.5 72-inch) coated

with an antibacterial ointment is firmly packed in a layered fashion toward

the posterior choanae after decongestion and local anesthesia placement


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Anterior Nasal packing

Newer nasal packingmaterialsexpandseveral times in volume

with hydration, makingplacement easier for thephysician and patienthydroxylated polyvinyl

acetal (Merocel) andpolyvinyl alcohol(Expandacell, RhinoRocket)

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Nasal packing posteriorIndicatedfor those patients

failing anterior nasal packs or

who upon evaluation have

known posterior bleeding

Preoperative procedure :

Require careful instruction

to the patient

Intravenous access andmild sedation

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Nasal packing posterior

Technique procedure :

The ideal pack will seat firmly in the posterior nasalcavity against the septum and floor of the noseshould not fill the nasopharynx or depress the softpalate

For the optimum distribution of pressure in theposterior nasal regiona conical-shaped rolledposterior nasal pack with the base oriented posteriorlyand out of the nasopharynx.

The posterior pack is generally used in conjunctionwith an anterior pack to stabilize it

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Monitoring post posterior nasal packing : Should be admitted and monitored in an appropriate hospital

setting.

Pulse oximetry is recommended to follow oxygen saturation.

Maintenance of body fluids is important.

Deep vein thrombosis in the bedridden and elderly patient is ofparticular concern

The gauze packing should be impregnated with antibiotic

ointment, which will decrease the microbial flora present.

The packing is usually left in position for an average of 3 to 5days.

If patients fail packing, they are candidates for further

intervention, determine to undertake a different initial procedure

based on the clinical presentation.

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Nasal packing posterior


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BALLOON PACKS

More available and variedthan the Foley catheter

balloon

Newer typesinclude

double balloons, a compositeof balloon and Merocel

advantage of staying in place

after balloon deflation and

removal.

30Adapted from : Miller, A.J. Epistaxis In : Bailey, B.J. Head & NeckSurgery-Otolaryngology. 2nd ed. 1998


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Complications :

A potential drawback of

balloon packs

Alar or columellar

necrosis

Adapted from : Miller, A.J. Epistaxis In : Bailey, B.J. Head &Neck Surgery-Otolaryngology. 2nded. 1998

Balloon packs


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Epi-dual epistaxis

catheter

Epi-mono epistaxis

catheter

Epi-lave epistaxis

catheter

www.bes.de/rhinologie/epistaxiskatheter


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3. epistaxis

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