Epistaxis

Question 1

What is epistaxis?

Answer 1

nosebleed

Question 2

What are the two types of epistaxis? what is the difference between the two?

Answer 2

anterior and posterior
anterior - visible source or bleeding
posterior - more profuse and originate from deeper structures -> bilat bleed, can’t locate on speculum

Question 3

which area is affected in anterior bleeds?

Answer 3

capillaries forming Kiesselbachs plexus (littles area)

Question 4

why are posterior bleeds more dangerous? who do they tend to occur in?

Answer 4

higher risk of aspiration and airway compromise

older pts

Question 5

what are local causes of epistaxis

Answer 5

i. TRAUMA - nose picking/blowing, foreign bodies, septal perforation, blunt trauma (falls in children)
ii. INFLAMMATION - inf, allergic rhinosinusitis, polyps
iii. TOPICAL DRUGS - cocaine, decongestants, CS
iv. VASCULAR - hereditary haemorrhagic telangiectasia, Wegeners
v. POST OP
vi. Tumours - benign (angiofibroma), SCC
vii. Nasal O2 therapy - dries mucosa

Question 6

What are systemic causes of epistaxis?

Answer 6

1. HTN - assoc but may not be causative
2. Atherosclerosis
3. Haematological conditions - thrombocytopenia, platelet dysfunction, vWD, leukaemia, haemophilia
4. Environment - temp, humidity, altitude
5. Systemic drugs - anticoagulants, antiplatelets
6. XS alcohol

Question 7

What are first aid measures for controlling nosebleeds?

Answer 7

1. Sit forward w mouth open
   pinch cartilaginous area for 15 mins while mouth breathing
2. decongest e.g. ephedrine 0.5% drops
3. Ice pack on dorsum of nose

Question 8

what is always the initial management of epistaxis?

Answer 8

check the pt is haemodynamically stable!!
ABCDE
resuscitate if needed

Question 9

What is the next step in management if first aid measures fail? what does this involve?

Answer 9

SILVER NITRATE CAUTERY

i. pt blows nose to remove clots
ii. topical local anaesthetic spray
iii. find bleeding point
iv. apply silver nitrate stick
v. dab area clean w a cotton bud and apply naseptin or muciprocin

Question 10

why must you only cauterise one side of the septum?

Answer 10

risk of perforation

Question 11

What is the next step in management after cautery?

Answer 11

Anterior nasal pack
I. anaesthetise w spray
ii. advance all the way into nose horizontally
iii. examine mouth + throat for any bleeding, consider packing other nostril

Question 12

What is the next management after anterior nasal pack?

Answer 12

postnasal pack

admit pts w packs

Question 13

how should you manage haemodynamically compromised pts?

Answer 13

admit to emergency department, control bleeding w first aid measures in interim

Question 14

What pts should be admitted to hospital ?

Answer 14

bleed from unknown or posterior source

Question 15

What is the management of posterior epistaxis?

Answer 15

1. examination under anaesthesia - If bleeding point found, rx directly e.g. diathermy
2. endoscopic ligation of maxillary/sphenopalatine artery
3. embolisation but risk of stroke

Question 16

What self care advice would u give to a pt following a nose bleed?

Answer 16

avoid:

• blowing/picking nose
• heavy lifting
• exercise
• lying flat
• drinking alcohol/hot drinks