QUIZ28thOct2020(answersbelow)
1. Outlineyourmanagementofepistaxis.
2. DescribethestepstoinsertaRapidRhino.
3. Whatdischargeinstructionsdoyougiveepistaxispatients?
4. Whatlaboratoryparametersshouldbemonitoredtoguideongoingmassivetransfusion?
5. DescribeandinterpretthefollowingECG.
QUIZanswers28thOct2020
1. Outlineyourmanagementofepistaxis.
A. ResuscitationParticularlyinsevereorprolongedepistaxis,considerneedfor:
• Airwaymanagement• Bloodtransfusion/MTP/Anticoagulationreversal• UrgentENTconsultation
B. Firstaid–(patientscanbeinstructedtodothisifithappensagain)GentlyblownosetoclearclotsPinchtheSOFTsidesofthenoseagainsttheseptumHoldfirmpressurecontinuouslyfor10minutesSitupandleanforward,spitoutanybloodinmouth+/-Coldcompressacrossbridgeofnose
C. ExaminationTrytodeterminewhichsidethebleedingstartedfromClearclotsout–bypatientgentlyblowingnose,orusesoftYsuctioncathetersnippedshortersothattherearenosideholesSprayCoPhyenycaineone/bothsidesVisualiseaffectedsidelookingforbleedingsite
HeadlightNasalspeculumMayneedmoresuctioning,wipingwithswab
D. OngoingbleedingCottonwoolpledgetssoakedinadrenaline1:1000
Patientcanapplyfirstaidpressurewithpledgetinplace10–20minCanalsotrypledgetsoakedintranexamicacid
*ConsiderposteriorbleedingUsuallynotminorbleeding
Bleedingfrombothnostrils Noanteriorsitefound Patientfeelsblooddrippingdownoropharynx
E. CauteryIfbleedingsitefound,cancauterizewithsilvernitratestick
Riskofperforationisonlyifcauterizingseptumbilaterally Thenapplysmallfoldedpieceofsurgicelanddischargeinstructions
F. PackingwithRapidRhinoOnlyiffailureofabovemeasuresCommitspatienttoadmissiontohospitalConsiderENThelppriortoinsertionasitcausestoomuchmucosaltraumatoremoveagainstraightawayforreexamination
2. DescribethestepstoinsertaRapidRhino.Ø Removebluecover
Ø Soakinsterilewaterforafull30seconds§ Don’tusesalineasitinhibitsthegellingcharacteristicsof
thefabric.§ Don’tuselubricantorantibioticointment,astheywill
inhibitthehaemostaticpropertiesofthefabric.
Ø Insertthedevicealongtheseptalfloorandparalleltothehardpalateuntiltheplasticproximalfabricringiswellwithinthenares.
Ø Usea20mLsyringeandinflatethedevicewithAIR.§ Stoptheinflationwhenthepilotcuffbecomesroundedand
feelsfirmwhensqueezed.§ Theamountofairdependsonthesizeofthepatient’s
nasalanatomy.
Ø Tapethepilotcufftothesideofthepatient’sface.
3. Whatdischargeinstructionsdoyougiveepistaxispatients?
Forthenext3days:Avoidexertion,strainingandheavyliftingAvoidsteaminghotfood,drinksandshowersAvoidnoseblowingUsevasoconstrictoreg.DrixineUsemoisturiseronnasalmucosabd
eg.Nasalate,chlorsigointment,bactroban,vaseline Providefirstaid(asabove)ifrecursandreturnifepistaxispersists
4. Whatlaboratoryparametersshouldbemonitoredtoguideongoingmassivetransfusion?
pH >7.2 Baseexcess <-6 Lactate <4mmol/L iCa >1.1mmol/L Hb Shouldnotbeusedaloneasatransfusiontrigger Platelet >50x109/L PT/APTT <1.5normal INR <1.5 Fibrinogen >1.0g/L
5. DescribeandinterpretthefollowingECG.
Rate 88/min SinusrhythmwithfrequentPVCsandfusionbeats
ThePVCsarefollowedbyacompletecompensatorypause,indicatingthatthesinustimingisnotinterrupted;onesinusPwaveisn'tabletoreachtheventriclesbecausetheyarestillrefractoryfromthePVC;thefollowingsinusimpulsecontinuesthesinusrateof88/min.
Pwaves NormalmorphologyPRinterval NormalQRS Narrow,normalaxis,normalaxis,normalRwaveprogressionSTsegments Depressedinferiorly(III,aVf,II) DepressionV4-5atJpoint,slopinguptoupright,symmetricalTwaves Elevation1mminaVR ElevatedV1-3leadinguptolargehyperacuteTwavesQTc Prolonged484msec
è CoronaryangiogramrevealedcompleteproximalLADocclusion
Thispatternof1-to3-mmupslopingST-segmentdepressionattheJpointinleadsV1toV6thatcontinuedintotall,positivesymmetricalTwavesisconsistentwith“deWinterTwaves”andindicatesproximalLADocclusion.Inmostpatients,thereisalso1-to2-mmST-elevationinleadaVR.DeWinderRAnewECGsignofproximalLADocclusionNEnglJMed2008;359:2071-2073
