Wednesday, 28 May 2014

Epistaxis


General
Epistaxis accounts for 1 in 200 visits to the ED. There is a general lack of general first aid knowledge but 85% of patients can be managed without specialist input.

Anatomy
Kiesselbach's plexus = the anastamoses that are joined together. Triangular nasal septum area = Little's area. Most bleeds are from this area (anterior, in 95%). 

Causes
Local minor trauma - nose picking
Drying out in the winter months.
In adults recent alcohol intake, surgery, local malignancy and aneurysm, drugs. 
No studies linking hypertension with epistaxis. 

History Red Flags
    nasal obstruction or congestion
    facial pain
    headaches
    facial numbness, particularly affecting the cheek or side of the nose
    pain around the eye or double vision
    reduced sense of smell
    pain or pressure in one of the ears
In young male patients consider juvenile nasopharyngeal angiofibroma and ask about nasal obstruction, headache, rhinorrhea, and anosmia. These are rare benign tumours that tend to bleed. They occur in the nasopharynx of pre-pubertal and adolescent males.

First Aid Treatment
Remember PPE
Pinch nose (Trotter's Method)
Suck on an ice cube
Ice pack to nose
Ice to neck forehead not shown to help

Further Management


Preparation
- Clean nose with gentle suction. A cut down suction catheter may be less traumatic.
- Might need LA vasoconstrictor applied by a spray or cotton wool pledget. 

- Blood tests not needed unless significant co-morbidity, history or evidence of coagulopathy and disturbance of haemodynamic observatons. Coagulation studies unnecessary unless personal or family history of a coagulation disorder.

- In children, naseptin cream is as good for preventing recurrent epistaxis as silver nitrate but cautery causes more pain. 

Cautery
- Cauterise by direct application for no more than 30seconds in any spot
- If bleeding is too brisk for cautery to be effective cauterise the four quadrants immediately around the bleeding site. 
- Don't do both sides of the nose at once.
- Excess silver nitrate can be removed by application of a saline soaked pledget to the area which neutralises the silver nitrate preventing staining and unwanted burning.

Packs

- All the way in so that you don't get a "Walrus sign". 
- Observe for 30minutes post packing. 
- Observe for longer post pack if:
    Traumatic cause for the epistaxis
    Haemodynamic compromise or shock
    Previous nasal packing within the last 7 days
    Patient is taking anticoagulant medication
    Measured haemoglobin less than 10 g/dl
    Uncontrolled hypertension
    Significant co-morbid illness
    Adverse social circumstances (e.g. the patient lives alone or more than 20 minutes away from the hospital or has no access to telephone or transport)

- Anterior packs for 24 – 48 hours 
- Routine antibiotic cover is not required

- Complications of nasal packing
    Failure to stem bleeding
    Toxic shock syndrome
    Blockage of
        – nasolacrimal duct leading to epiphora
        – sinus drainage leading to acute sinusitis
        – nasal airway leading to hypoxia
    Nasovagal reflex: this reflex occurs during insertion of a pack or instrumentation of the nasal cavity. It leads to vagal stimulation, with consequent hypotension and bradycardia
 
Merocel - easier to insert. 
- Nasal tampons need lubrication with jelly
 
Rapid Rhino - less painful to insert and easier to remove.
- Rapid rhinos need water for at-least 30seconds
 
Foley catheters - advance through nostril until seen in the pharynx. Each balloon should be inflated with 5 - 10mls water and gentle traction applied.

Discharge Advice
Avoid:
    Blowing the nose for one week.
    Sneezing through the nose – keep the mouth open.
    Hot and spicy drinks and food, including alcohol for two days.
    Heavy lifting, straining or bending over.
    Vigorous activities for one week.
    Picking the nose.

References

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