case epistaxis

7/26/2019 Case Epistaxis

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Case Study

A 34 female presents to ED at 2am, post waking up with blood all over her pillow, and a

continuos ooze of blood from her right nostril.

n e!amination the patient is alert and oriented, "# $$%&'%, pulse (), respirator* rate 22, +p%2(- room air, and has no past medical histor*. he patient reports having a sinus infection of

late which she/s has been using an antihistamine nasal spra* to treat.

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Epistaxis:

Epista!is is a freuent complaint '%- of the populationwill with suffer from a nose bleed during their lifetime, and '-

will reuire medical attention.

aorit* of epista!is occurs between the ages of 25$% and )%5% *ears old.

Epista!is results from an interaction of factors that damage the nasal mucosal lining,

affect the vessel walls, or alter the coagulabilit* of the blood.
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Emergenc* ph*sicians have a (%- success rate at treating epista!is in emergenc*

department, and onl* have to refer $%- to E6 for further assessment and management

Causes of Epistaxis:

Local trauma:

6ose picking

7acial trauma

7oreign bodies

6asal or sinus infections

6asal septum deviation

Environmental:

Dr* cold conditions 8presentations increase during winter9

#rolonged inhalation of dr* air 8!*gen9

Iatrogenic:

6asogastric tube insertion

6asotracheal intubation

Medicinal:

opical corticosteroids and antihistamines +olvent inhalation 8huffing9

+norting cocaine

Anticoagulants1 Aspirin, warfarin, platelet inhibitors

Coagulopathies:

0nherited coagulopathies1 von :illebrand disease, haemophilia A ; "

+plenomegal*

hromboc*topenia

#latelet disorders

hronic alcohol abuse


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A0D+

Vascular Abnormalities:

+clerotic vessels

?ereditar* haemorrhagic telangiectasia

Ateriovenous malformation

6eoplasm

Aneur*sms

+eptal perforation&deviation

Endometriosis

ypertension:

>ontroversial topic and is often misunderstood in epista!is @ see ?*pertension and

Epista!is.

?*pertension is rarel* a direct cause of epista!is

Epista!is is however more common in h*pertensive patients this is postulated to be

caused from long standing h*pertension causing vascular fragilit* of the blood vessels.

Epista!is in patients presenting to ED, will generall* have an associated an!iet* that will

increase blood pressure.

Despite multiple causes for epista!is, literature shows that in )- of cases no causes in found.

Anatomy and !hysiology of Epistaxis:

he nose is supplied with an e!tensive vasculature with multiple anastomosis.

(%- of epista!is occurs in the anterior nasal septum, from


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Anatom* of the 6asal >avit*1 0mage from1http1&&3.bp.blogspot.com

Assessment of the patient presenting "ith Epistaxis:

istory:

btain the following1

urrent medications

!hysical Examination:

7ocus on tr*ing to identif* if the bleed is coming anteriorl* or posteriorl*.

+uctioning or blowing of the nose to clear awa* clots, and application of topical

vasoconstrictors or anaesthetics will help with visualisation
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Bentl* insert nasal speculum and spread naris verticall*, a good light source will be also

reuired to assist visualisation of bleeding area.

A posterior source of bleeding is suggested b* failure to visualise an anterior source,

bleeding from both nares, and the visualisation of blood in the posterior phar*n!.

Investigations:

#atients will large amounts of bleeding should have a full blood count to check

haemoglobin level, and a group and hold incase transfusion is reuired# #atients taking warfarin should have an 06= checked.

>oagulation studies are onl* of benefit in patients with a known coagulopath* or chronic

liver disease, and should not be routine in patients presenting with epista!is.

ther bloods test should onl* be ordered if past medical histor* warrants further

investigation 8renal failure C ;E, chronic alcohol abuse C scan is

indicated if neoplasm suspected, and would generall* be arranged post consultation with

*our E6 specialist.

Emergency $epartment Management:

!rehospital Care:

Bood effective first aid should stop (%5()- of nose bleeds. #rovide a calm and uite area for the patient to decrease an!iet*

he patient should position them self either forward or backward, which ever provides

the most comfort and prevents the patient from swallowing or aspirating an* blooddraining into the phar*n!. ip1Fresh blood is irritating to the stomach and will cause

nausea and vomiting.

#ressure should then be applied b* pinching the anterior aspect of the nose for $)5

2%mins, which provides tamponade to the anterior septal vessels. #atients should be

shown the correct was to appl* pressure b* avoiding the nasal bones, b* pressing moredistall* the nasal ala against the septum.

+ome authors advocate placing ice pack to the nape of the neck with belief it produces a

refle! vasoconstriction in the nasal mucosa, however there is little research or evidence tosupport this.

Initial Management and %esuscitation:


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0n e!treme cases patients can present with uncontrolled haemorrhage, standard resuscitation

principles should be applied.

Airwa*1

=isk of airwa* obstruction from blood in the posterior phar*n!, or decreased level ofconsciousness from h*povolaemia.

#lace patient in postion to assist in managing the blood loss, ma* reuire freuent

suctioning.

"e prepared to secure and place a definitive airwa* 8E9

"reathing1

Assess depth of breathing and respirator* rate,

=emember a nois* airwa* is an occluded airwa*

#rovide high flow o!*gen via non rebreather mask

>irculation1

Assess heart rate, blood pressure and capillar* refill

#atient at risk for severe haemorrhage place !2 large bore 0, check ?", cross match

blood, and start fluid resuscitation

Disabilit*1

onitor patients level of consciousness this help determine the severit* of haemorrhage

E!posure1

eep patient warm to prevent coagulopath*

0f epista!is is caused b* maor trauma, alwa*s e!amine from for other inuries

#atients can and have died from epista!is be prepared to resuscitateFFF

Vasoconstriction:

asoconstriction can be achieved b* the application of agents topicall* or soaked cotton

pledgets inserted into the nasal cavit*.


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asoconstrictors have been shown to be e!tremel* effective in anterior epista!is, aid in

the visualisation of the bleeding site, and assist if packing is reuired.

7ollowing successful application of topical vasoconstriction, patients should be

encouraged to appl* topical steroid creams, and petroleum ell* to the nasal cavit*

weekl* for si! weeks, this has been shown to have a (4- success rate of resolution of

s*mptoms.

Suction:

+uction should be available and eas* accessible to help remove clots.

Betting the patient to blow their nose can also be an effective form of suction

An angled 7raser sucker, $%5$2 7rench gauge, is preferred to allow evacuation of the

anterior and middle nasal cavit*

Cautery:

>hemical1

>hemical cauter* involves the application of silver nitrate sticks, b* wiping the tip of the

silver nitrate stick over littles area until it becomes discoloured and gre*.

he area should be suctions and as dr* as possible to ma!imise the effectiveness of silver

nitrate sticks, localised pain can occur on application.

he sticks should be applied for 45)secs until a gre* residue or eschar develops.

nl* one septum should be cauterised using silver nitrate, as bilateral can cause sepal

perforation

Benerall* effective in anterior bleeds, however there is a risk of rebleeding.

Electrocauter*1

Benrall* performed b* E6 specialist after effective topical anaesthetic needs to be

provide first.

he red5hot electrocauter* loop is passed over the mucosal blood vessels effecting

cauter*.

opical antibiotics and&or petroleum ell* can be used postoperativle*.

!ac&ing:

Anterior packing is reuired when the bleeding fails to stop with vasoconstrictors and

cauter*# ptions include traditional nasal packing, a prefabricated nasal sponge, an epista!is

ballon, or absorbable materials.


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6asal tampons that are moistened, gel5coated, with an inflatable balloon are less painful

and show eual effectiveness when compared to dr* h*drophilic nasal tampon

*pes of packs1

Traditional Vaseline gauze packing1 generall* not used these da*s, as have beensupplanted b* readil* available and more easil* placed tampons and balloons.0t consist of

ribbon gauze soaked in petroleum ell*, and is placed in the back of the nasal cavit* as far

back as possible, and la*ered into the naris until it is completel* packed. 6eed to allow

both ends of the gauze protrude from the nose to allow ease of removal.

Compressed sponge/tampon1 erocel is a deh*drated pol*vin*l pol*mer sponge, formed

into flat tampons of various sizes. hese are inserted into the nasal cavit*, and then

reh*drate b* blood or saline, causing then to e!pand up the three time their original size,filling the nasal cavit* and compressing the source of bleeding.he advantage of these of

gauze packing is that the* are technicall* easier to insert, however literature shows no

difference in patient pain, and ease of removal compared to gauze packing.

Anterior epistaxis ballons:=apid =hino consist of an outer la*er of carbo!*cellulose that

promotes platelet aggregation, with an inflatable balloon that compresses the nasal cavit*

upon inflation tamponading the bleeding site. =apid =hino have been shown to be aseffective as nasal tampons and allow for superior patient comfort on insertion and

removal.

Absorbable materials1 various non5absorbable packing materials are available, including

carbo!*meth*cellulose sponges, and calcium alginate dressings and wicks. hese

dressing can be left in place for between $5) da*s, but remember the longer the packing isleft insitu the increase risk of developing to!ic5shock s*ndrome.

!osterior !ac&ing' (allon Catheters:

#osterior nasal bleeds can be difficult to manage related to the relativel* inaccessible site

of bleeding and generall* don/t respond the above standard medical treatment and

packing.

Analgesia will be reuired for patients with posterior packing and ballon catheters

Double balloon catheters consist off of a posterior and anterior balloon, are relativel*

eas* to insert, although cost ma* limit their use. Benerall* used in difficult posteriorepista!is.

he catheter is inserted to the back of the nasophar*ngeal space, and then inflate theposterior balloon first and bring forward sealing off the postnasophar*ngeal space. hen

inflate the anterior ballon to appl* pressure to the internal cavit* of the nose.

+aline is preferred over air to inflate balloon as air can leak out causing deflation and

further rebleeding.

Avoid over5inflating ballon catheters as will cause increased discomfort, rupture of the

ballon, or pressure necrosis of the nasal mucosa.


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A fole* catheter can be used $%5$4 7rench with 3%ml balloon as an alternative.

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$isposition:

Arrange admission for patients with posterior packing, reuiring o!*gen, and patients

with difficult to manage bleeds.

#atient with anterior packing can generall* be discharged home, with packing insitu, with

follow up arranged in 45G2 in the E6 clinic. #rovided antibiotics and oral analgesia.

#atients with chronic epista!is should receive medical followup to investigate anaemia

from chronic blood loss, and coagulopathies. ncontrolled severe epista!is can sometimes reuire endoscopic cauter*, embolization or

arter* ligations, patients at risk should receive earl* E6 review.

>onsider rane!amic acid is severe epista!is as it works as a potent competitive inhibitor

of plasminogen activator and thus of the fibrinol*tic s*stem, and ma* therefore prevent

clot disintegration and reduce the likle*lihood of rebleed.

Medico)legal !itfalls:

6asal packing can lead to serious infection 8o!ic shock s*ndrome9, most of literature

and E6 specialist recommend proph*lactic antibiotics, until evidence supports orrefutes this practise its most probabl* best practise to follow this and treat with broad

spectrum antibiotics. #osterior nasal packing places the patient at risk of h*po!ia and h*poventilation,

monitoring for this, and implement treatment promptl* should it occur.

6asal packing generall* slows or causes cessation of haemorrhage, failure to control

haemorrhage should prompt urgent E6 review.
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=ecurrent unilateral epista!is should prompt further investigation to rule out neoplasm.

H6ose bleeds occur in those who are beginning to have feeling of lust or who are getting the

signs of manliness.I

case epistaxis

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