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

http://www.enlightenme.org/knowledge-bank/cempaedia/acute-epistaxis
http://www.enlightenme.org/learning-zone/epistaxis-child

http://www.enlightenme.org/learning-zone/doctor-please-deal-my-bleeding-nose
http://www.enlightenme.org/node/2143
http://www.enlightenme.org/knowledge-bank/cem-ctr/nasal-packing-acute-management-anterior-epistaxis-appraisal-available-options 

http://www.doctors.net.uk/ecme/wfrmNewIntro.aspx?moduleid=1072
http://lifeinthefastlane.com/epistaxis/

http://emj.bmj.com/content/22/7/470.full 

https://www.emrap.org/episode/2013/april/epistaxis

https://www.emrap.org/episode/2014/march/paperchase2
http://pmj.bmj.com/content/81/955/309.full 

http://thesgem.com/2013/11/sgem53-sunday-bloody-sunday-epistaxis-and-tranexamic-acid/
http://emlyceum.com/tag/epistaxis/ 

http://www.emlitofnote.com/2013/09/tranexamic-acid-for-epistaxis.html

http://learning.bmj.com/learning/module-intro/.html?moduleId=5003351
http://lifeinthefastlane.com/education/ccc/epistaxis/
http://emergencyeducation.net/epistaxis.html

http://intensivecarenetwork.com/georgie-harris-on-massive-epistaxis-an-ent-perspective/
http://www.edtcc.com/blog/2011/12/18/myth-buster-episode-2-hypertension-and-epistaxis.html 

http://www.bmj.com/content/344/bmj.e1097?sso=
http://emj.bmj.com/content/22/10/724.long 

https://twitter.com/AndyNeill/status/435485558568390656

http://emwestvirginia.wordpress.com/2014/02/17/epistaxis-in-the-emergency-department/
http://academiclifeinem.com/trick-of-the-trade-epistaxis-control-with-tongue-blades/
 

Dental Blocks

It's on our syllabus that we should be able to do dental nerve blocks - and I suppose we should all be happy to at least give it a try. There are lots of potential dental nerve blocks that can be used. The Oxford Handbook only mentions two of them, so I'm only going to cover those two.

Infraorbital Nerve Block


- Supplies the skin and mucous membrane of the cheek, upper lip, lower eyelid and side of the nose.
- Emerges from the infraorbital foramen (0.5cm below the infraorbital magin and vertically below the pupil).
- Insert the needle into the buccogingival fold between the first and second premolars and direct it up towards the infraorbital foramen.


Mental Nerve Block


- Sensation to the lower lip and the chin
- Emerges from the mental foramen, which is palpable on the mandible on a line between the first and second premolar teeth.
- Block at mental foramen with 1-2ml of LA
- Intraoral or extraoral approach

http://www.emergpa.net/wp/wp-content/uploads/Emergency-Dental-Handbook.pdf

http://www.ncemi.org/cse/cse0420.htm

TMJ Dislocation

Identification
- 90% of cases are bilateral
- Most common cause is excessive mouth opening
- Anterior dislocations are most common.
- Posterior, lateral and superior dislocations are associated with a fracture.

Preparation
- Protect your thumbs with gauze rolls around each thumb.

- Adequate analgesia
- Consider intra-articular lignocaine
- X-ray to confirm reducation and no fracture. May not be necessary if pain settled completely.

Procedure
Massage masseter muscles
Apply rotational force on the mandibular ramus





After Relocation Advice
- Keep jaw closed for next 24hours
- Head bandage if chronic
- Soft diet

References
http://academiclifeinem.com/trick-of-the-trade-massaging-a-mandibular-dislocation-back-in/
http://academiclifeinem.com/trick-of-the-trade-protecting-your-thumbs-in-mandible-relocations/
http://academiclifeinem.com/trick-of-the-trade-stabilizing-mandibular-relocations/
http://crashingpatient.com/medical-surgical/oral-medicine-and-dentistry.htm/
http://academiclifeinem.com/trick-of-the-trade-temperomandibular-tmj-dislocation/
http://www.enlightenme.org/knowledge-bank/cempaedia/mandibular-and-temporomandibular-joint-injuries
http://emedicine.medscape.com/article/149318-overview

Dental Fractures

The first step is to have a look at the tooth and work out what tooth it is.

Then have a look and try and work out what is wrong with it. See what it looks like. See if it's sore. See if it wobbles.

Concussed
 - no obvious displacement. Tender to touch.
- not wobbly.
 - soft food for a week


Subluxation
- Increased mobility and pain
- Some associated bleeding
- Increased mobility
- Soft food, clean carefully, chlorhexidine mouthwash.

Extrusion
- Partial displacement of the tooth out of its socket
- Partial or total separation of the peridontal ligament resulting in loosening and displacement of the tooth.
- Tooth appears elongated
- If <3mm in an immature developing tooth, needs careful repositioning.

Intrusion
- May or may not intersect the secondary tooth bud.
- May penetrate into the nasal cavity.
- Often associated with alveolar fracture.
- Needs repositioning and careful advice.

Avulsion
- Empty socket
- Do not replace
- Consider x-ray to check not aspirated. Soft food for a week.

In adults
- Wash briefly
- Reposition
- Bite on a hankerchieft to hold it in position
- Glass of milk for storage.
- Flexible splint for two weeks

Infraction
Crack - No follow up needed

Enamel Fracture
Smooth sharp edges

Alveolar Fracture
Manual repositioning + stabilising of the segment
Monitor
Soft diet

Tooth Fractures
These need things done to them. You can catagorise them using the Ellis staging system. I'm going to refer them all to max fax/ a dentist.

Post Extraction Problems

Bleeding - rolled up piece of gauze in the socket for 10min. May need horizontal matress suture - use lidocaine + adrenaline. 

Dry socket pain - if bone exposed. Typically 3- 8 days later. Irrigate with warm saline, oral antibiotics, analgesia and dentist. 

http://www.annemergmed.com/article/S0196-0644%2809%2901141-X/abstract
http://emin5.com/2014/04/07/dental-fractures/
http://www.dentaltraumaguide.org/Permanent_Alveolar_fracture_Description.aspx

Dental Emergencies

Incisors grow at 6 - 10months

Canine 16 - 20months

Molars 10 - 24months

Secondary incisors grow at 7 -8 years

Canine + pre-molars at 11- 13years

Molars 6 - 25years

Abscess

Likely to be streptococcus or staph aureus.
In history ask when it started, whether antibiotics used, about presence of systemic features, and immunocompromised. 

Not all patients need antibiotics - give if systemically unwell, high risk or likely complications. 

Amoxicillin or metronidazole - either works.

Admit if systemically unwell, antibiotics no help, rapid spread, dysphagia or dysphonia, immunocompromise or GA needed.

Vincent's Angina

Acute necrotising ulcerative gingivitis or trench mouth

Causes pseudo-membranous infection.
Needs chlorhexidine mouthwash with metronidazole or amoxicillin.
Dental review ASAP. 

 

Ludwig' s Angina - submandibular abscess

Mostly affects males, between 20 -60 years old
Peri-apical abscess of the 2nd or 3rd molar penetrates the inner cortex of the mandible and gains access to the area inferior of mylohyoid. The infection tracks posteriorly so the sublingual space is involved.
The tongue is forced upwards and backwards.
It causes fever, pain, drooling, trismus, dysphagia, submandibular mass and dyspnoea.

Hot potato voice.

Lemierre syndrome

Thrombophlebitis of the jugular veins with distant sepsis of oropharyngeal infection (pharyngitis / tonsilitis +/- peri tonsillar abscess). Caused by an anaerobic gram-negative bacillus.
Patients present unwell, trismus and pain behind the angle of the jaw.

USS shows thrombophlebitis of the internal jugular vein which is often the first hard evidence to suggest Lemierre's.

Referenceshttp://emj.bmj.com/content/21/2/242.full
http://journals.lww.com/em-news/Fulltext/2004/02000/Diagnosis__Ludwig_s_Angina.14.aspx 

http://www.emspecialists.com/news/1110/ludwigs_angina.htm 

http://www.aafp.org/afp/1999/0701/p109.html

http://radiopaedia.org/articles/lemierre-syndrome
http://www.intjem.com/content/6/1/40

http://casereports.bmj.com/content/2013/bcr-2013-201868.extract

http://www.emergucate.com/2012/08/14/the-daily-educational-pearl-vincents-angina/

http://academiclifeinem.com/paucis-verbis-dental-infections/

Haematology Summary

 I think we've covered everything the syllabus wants us too for adult haematology.

Acute Leukaemia

As always, check out the Calgary Guide for the pathophysiology of leukaemias. The important thing to realise is that Chronic Myeloid Leukaemia (CML) can progress into AML or ALL.

Chronic Myeloid Leukaemia

Incidence of 1 per 100 000 population. Symptoms are usually chronic and non-specific, but splenomegaly is common and may extend beyond the umbilicus. Lymphadenopathy is not usually prominent. Neutrophilia is common and may be accompanied by thrombocytosis, basophilia, monocytosis, or eosinophilia.

Acute Leukaemias

Acute Lymphoblastic Leukaemia
Rare
Common at 2-10 years with a peak at 3-4 years
Secondary rise after 40 years
Acute lymphoblastic leukaemia is slightly more common among males than females

Acute Myeloid Leukaemia
10-15% of childhood leukaemia but is the commonest leukaemia of adulthood
Incidence increases with age, and the median age at presentation is 60 years.
Acute myeloid leukaemia is equally common among males and females

General
Clinical Features
Bone Failure - signs of anaemia.
  neutropenia - infections of the mouth, throat, skin or perianal region
  thrombocytopenia - spontaneous bruising, menorrhagia, bleeding from venepuncture sites, gingival bleeding or prolonged nose bleeds
Organ infiltration
“B symptoms”- fevers, night sweats, and unexplained weight loss

Investigations
- Anaemia - normocytic
- Low platelets
- Low white cell count - neutropenia with lymphocytosis
- Coagulopathy
- Hyperuricaemia
- Chest radiography is mandatory to exclude the presence of a mediastinal mass

References
http://calgaryguide.ucalgary.ca/slide.aspx?slide=Overview%20of%20blood%20cell%20malignancies.jpg
http://calgaryguide.ucalgary.ca/slide.aspx?slide=Pathophysiology%20behind%20the%20leukemias.jpg

http://www.bmj.com/content/346/bmj.f1660?sso=