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EPISTAXIS

EPISTAXIS. VTS presentations April 2013 Elisabeth Maskrey. EPISTAXIS CAN BE SERIOUS ……. Epistaxis – the facts. ~ 60 % of the general population has had at least one episode of epistaxis only 6% sought medical help 1.6 in 10,000 required hospitalisation

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EPISTAXIS

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  1. EPISTAXIS VTS presentations April 2013 Elisabeth Maskrey

  2. EPISTAXIS CAN BE SERIOUS ……

  3. Epistaxis – the facts • ~ 60 % of the general population has had at least one episode of epistaxis • only 6% sought medical help • 1.6 in 10,000 required hospitalisation • the incidence peaks < 10 and >50 years • rare in children < 2 years, if present is often associated with injury or serious illness • Types: • anterior bleeding • posterior bleeding • may present as hematemesis,nausea, anemia, hemoptysis,melena

  4. Epistaxis - risk factors • climate • deviated nasal septum • Trauma • inflammation • irritant chemical exposure • Disorders of platelet function • Drugs • Abnormalities of blood vessles - elderly arteriosclerotic vessels, hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber syndrome) • Malignancy of the nose - juvenile angiofibroma • Wegener's granulomatosis and pyogenic granuloma

  5. Epistaxis – Hx, examination and Investigations ABC to confirm haemodynamic stability Hx • laterality, duration, frequency, and severity • PMHx including any conditions predisposing to bleeding - coagulopathies • current medication - aspirin or warfarin • FHx of bleeding disorders • history of recent trauma or surgery • presence of unilateral symptoms like nasal obstruction, rhinorrhea, facial pain, or evidence of cranial neuropathies (facial numbness, double vision) indicating benign or malignant sinonasal neoplasms Examination • Ideally Thudicum nasal speculum under adequate lighting to identify bleeding points • if a blood clot is present, advice the patient to blow their nose (with caution) or suction • topical sprays containing a combination of anesthetics and vasoconstrictors can be used to control bleeding Investigations • Sever hemorrhage – FBC, coag, G&S and CXM • On warfarin - FBC, coag • Systemic conditions – LFT and U&E

  6. Management Direct pressure • Sit patient upright, leaning slightly forward • Patient squeezes the bottom part of the nose (NOT the bridge of the nose) for 10-20 minute • Monitor HR and BP • If bleeding has stopped after this time inspect the nose using a nasal speculum and consider cautery. Cauterisation • Apply a silver nitrate cautery stick for 10 seconds • working from the edge and moving radially • Never both sides of the septum at the same session. Cream (Naseptin) • Cautery and cream are equally effective for the treatment of epistaxis. • Application of a cream-based treatment may initially be easier and more practical, particularly in children

  7. Management Anterior packing • nasal tampon • absorbs blood, swells and the tight fit reduces flow. • Lubricate the tampon with K-Y Jelly or Naseptin cream • secure the tampon thread to the cheek • Pack the other side as well. • Packs are generally left in place for 24 hours. • Can also use 1 cm ribbon gauze impregnated with petroleum jelly . Both ends of the gauze should protrude from the nostril. Posterior bleeds • May require ENT input • packing and a balloon catheter can be useful • Opiate analgesics to relieve discomfort and reduce elevated blood pressure due to posterior pack. • Ligation of the sphenopalatine artery endoscopically.

  8. Management Complications of packing • Anosmia • Pack falling out and continued bleeding • Breathing difficulties and aspiration of clots • Posterior migration of the pack causing airway obstruction and asphyxia • Perforation of the nasal septum or pressure necrosis of cartilage

  9. Summary • If sever get specialist help • For recurrent cases consider underlying causes • Can be managed quickly and easily in most cases

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