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