EPISTAXIS. Nasal Trauma, and other emergencies. Marc A. Tewfik MDCM, MSc, FRCSC

Transcription

1 EPISTAXIS Nasal Trauma, and other emergencies Marc A. Tewfik MDCM, MSc, FRCSC Assistant Professor, McGill University Otolaryngology-Head & Neck Surgery

2 DISCLOSURES Speaker/Consultant Merck Novartis MEDA Investigator in RCT Sanofi Royalties for book sales Thieme

3 EPISTAXIS MANAGEMENT 1. Three illustrative, but true to life, case studies 2. Clinically relevant history taking, physical exam and investigations 3. Management principles based on intranasal vascular anatomy 4. Techniques for achieving hemostasis 5. Discussion of some critical clinical issues including treatment complications

4 CASE 1 Your close friend knows that you are a Med Student. She calls you one day indicating that she is presently bleeding from one side of her nose. It is only a slight bleed but it has been a recurrent problem. What immediate medical advice would you offer your friend?

5 CASE 1 RESPONSE CHOICES 1. Call 911 or go immediately to the closest ER 2. Lean forward over the sink and wait patiently until the bleeding stops 3. Firmly pinch the soft part of the nose for 5-10 minutes 4. Instill a large cotton ball lubricated with Vaseline into the nose 5. Vehemently deny that you are a medical student

6 Case 2 You are now on clerkship rotation in the ER. The triage clerk quickly admits a young man who sustained nasal trauma and is bleeding briskly. It appears that he has lost a considerable amount of blood. What are you immediate management options?

7 Case 2 - Response Choices 1. Start with a thorough 20 minute history 2. Find a computer and Google epistaxis management advice 3. Look for the busy attending staff to handle the case 4. Quickly pack the nose to control the bleeding then start an IV 5. A coffee break at this time sounds good

8 Case 3 You are now on rotation in the Family Medicine setting. A 55 year old female presents with a history of recurrent epistaxis but she is not currently bleeding. She is generally in good health but does indicate that she has mild hypertension. How would you manage this patient?

9 Case 3 - Response Choices 1. Take a thorough history 2. Do a complete physical examination 3. If necessary, proceed with relevant investigations 4. All of the above 5. I am still in denial that I have entered my clerkship year

10 EPISTAXIS Congenital Hemophelia A/B, von Willebrands HHT Inflammatory Trauma Dryness Digital Neoplastic

11 EPISTAXIS HISTORY Nasal trauma, winter dryness, previous surgery, cocaine abuse Family history of bleeding: HHT Other features to suggest coagulopathy Current medications: nasal steroid sprays, anticoagulants

12 EPISTAXIS EXAMINATION Adequate visualization of the nasal chambers is important Proceed with a proper Head and Neck exam including the upper aerodigestive tract A thorough general exam is necessary to exclude hypertension, bruising, splenomegaly, lymphadenopathy

13 PHYSICAL EXAMINATION

14 PHYSICAL EXAMINATION

15 Anterior View

16 EPISTAXIS LABORATORY INVESTIGATIONS Bloods: CBC, Coagulogram, Liver function Endoscopic evaluation of the nasals chamber and upper aerodigestive tract Sinus CT scan, MRI, Angiography

17 EPISTAXIS local causes Kiesselbach s plexus systemic causes requires a workup

18 EPISTAXIS ANTERIOR VS. POSTERIOR Kesselbach s Plexus/Little s Area: Anterior Ethmoid (Opth) Superior Labial A (Facial) Sphenopalatine A (IMAX) Greater Palatine (IMAX) Woodruff s Plexus: Sphenopalatine artery

19 Anterior and Posterior Ethmoid Arteries

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21 Sphenopalatine A Ethmoid A Greater Palatine A

22 ANTEROR EPISTAXIS Kisselbach s plexus (Little s Area) Trauma : nose picking Dryness Anticoagulants

23 POSTEROR EPISTAXIS 10% of all epistaxis - usually in the elderly To R/O when severe with Hb drop Atherosclerosis, HTN Neoplasm Anticoagulants

24 EPISTAXIS MANAGEMENT: ABCs! Protect self and staff Airway: ensure patency and protection Breathing: ensure adequate oxygenation Circulation: Addresses hemorrhage by applying local pressure Two large bore IVs, begin fluid resuscitation if necessary Labs

25 EPISTAXIS MANAGEMENT Once well controlled, proper examination including headlight or rigid endoscopy, Fraser suction, packing and clot removal Evacuate clots Identify source Topical vasoconstrictor, hemostatic agents, and anesthetic Reverse anticoagulation, lower BP

26 Video

27 Technical aspects for EPISTAXIS management Anesthesia and Vasoconstruction

28 Technical aspects for EPISTAXIS management Visualization Equipment

29 Technical aspects for EPISTAXIS management Instruments

30 Technical aspects for EPISTAXIS management Chemical Cauterization

31 SILVER NITRATE Video

32 Technical aspects for EPISTAXIS management Anterior Packing

33 ANTERIOR EPISTAXIS MANAGEMENT Anterior Sites cautery tamponade (packing) Risks of packings Toxic Shock Syndrome Antibiotic prophylaxis (staph aureus)

34 Video

35 Technical aspects for EPISTAXIS management Posterior Packing

36 POSTERIOR EPISTAXIS MANAGEMENT Need analgesia require admission and 02 saturation monitoring

37 Balloon Packing

38 Video

39 Critical clinical issues 1. Degree of blood loss and need for blood / volume replacement 2. Work up for an underlying coagulopathy or other systemic disease 3. Treatment of the anticoagulated patients with severe epistaxis 4. Need for an intranasal biopsy or specific investigation to R/O intranasal tumor or vascular lesion 5. The patient with unrelenting hemorrhage despite long term packing endoscopic sinus surgery, embolization 6. Complications of nasal packing including acute sinusitis, OSA and toxic shock syndrome

40 EPISTAXIS PREVENTION Humidifier Lubrification nose Saline spray Gel Vaseline

41 What if your broken nose doesn t bleed? SEPTAL HEMATOMA!! Bilateral fusiform swelling of septum Nasal obstruction If unrecognized: Septal abscess Cartilage necrosis Saddle nose

42 Saddle Nose Deformity

43 Emergency Drainage of Septal Hematoma

44 COMPLICATIONS OF SINUSITIS

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47 IMAGING: CT +/- MRI

48 RED FLAGS FOR URGENT REFERRAL Systemic toxicity Altered mental status Severe headache Swelling of the orbit or change in visual acuity