Epistaxis Flashcards
(24 cards)
5 characteristics of anterior epistaxis
From anterior nose Usually unilateral Lower volume bleed Frequent, come and go Most common
List 5 characteristics of posterior epistaxis
From posterior nose - can taste blood Bilateral from nostrils, also from mouth Higher volume bleed Most likely in elderly vasculopaths Look shocked (tachycardiac, hypotensive)
List 2 local causes of epistaxis
Mucosal trauma (macro and micro) Vessels (increased blood flow, abnormality)
How does HTN cause epistaxis?
By leading to atherosclerosis
Is an exacerbating factor for epistaxis (will increase volume and duration of bleed)
List 3 reasons blood flow to the nose might be increased
Infection
Heat
At night
Why does blood flow to the nose increase at night?
Due to increased PNS drive
List 2 systemic causes of epistaxis
Atherosclerosis
Coagulopathy
Principles of resuscitation
Airway (+ cervical spine) Breathing Circulation Disability (i.e. neurological issues) Everything else (All can be relevant in the setting of epistaxis)
Why are elderly vasculopaths most likely to suffer a posterior epistaxis?
More fragile blood vessels due to atherosclerosis and arteriolosclerosis
Characteristics of class I haemorrhagic shock
Lower volume Normal HR Normal BP Normal pulse pressure Normal RR Normal UO No CNS or mental state changes
Characteristics of class IV haemorrhagic shock
High volume (>2L) High or low HR Low BP Low pulse pressure High RR Very low or absent UO Decreased mental state (otunded?)
Characteristics of class II haemorrhagic shock
Normal BP (compensating with HR)
Slightly increased RR
Normal UO
Anxiety (sympathetic drive)
Characteristics of class III haemorrhagic shock
Decreased UO
Agitated (sympathetic drive and other emotional factors)
List 6 relevant behavioural modification to treat epistaxis
Avoid triggers (e.g. nose picking) Diet Exercise Sleep Environmental modification Mood management
List 4 relevant non-pharmocological treatments for epistaxis
Hygiene measures
Moisturisers
Saline rinsing
Dietary supplements
Ladder of intervention
Local pressure
Get BP down (calm patient down, pharmacological interventions if required including Ca2+ channel blockers and sedatives - benzodiazepenes, morphine but ensure airway is protected; NOT GTN because venodilator will increase bleed)
Vasoconstrictors
Cautery
Anterior packing
Posterior packing
Surgical miracles (e.g. endoscopic, open, angiography)
3 types of vasoconstrictors to treat epistaxis
Adrenaline (a and B non-selective adrenergic agonist) Cocaine HCl (LA: sodium channel block, NA reuptake inhibition; extra benefit due to numbing of nose) Phenylephrine, oxymetazoline (a-adrenergic agonists)
Do you ever use a posterior pack just by itself?
No - requires anterior pack
Also best to do both sides, front and back (bleed will probably be bilateral)
Angiography
Multiple vessel ruptures
Telangiectasias (?Osler-Randall-Wavler syndrome, congenital condition)
Von Willbrand disease
Presentation mimics platelet disorder not coagulopathy (unless no vWF, which is an AR inherited condition, in which case presents like thrombophilia as vWF carries FVIII around)
Typical features of coagulopathies
Large bruising on trunk and limbs
Relatively slight bleeding from cuts
Nosebleeds and GI bleeds uncommon
Haematuria common
Haemarthrosis in severe haemophilia
Up to a day’s delay before bleeding after surgery or dental extraction
Very heavy menstrual periods?? (or platelet disorder?)
Typical features of platelet disorders and von Willebrand’s disease
Lots of small bruises
Investigations
FBE (may not reliable immediately post-epistaxis; will have low Hb a day after, or following resuscitation, due to restoration of volume without restoration of RBCs)
Clotting factors
U&E
Blood group, crossmatch (will initially give crystalloid not colloid, then transfusion once able)
Dehydration
Loss of free water, nothing else
