Source of 90% of nosebleeds
Kiesselbach plexus on the anterior septum
The superior labial branch of the facial artery joins the anterior ethmoidal and terminal branch of the sphenopalatine artery to form the Kiesselbach plexus
The most likely source for posterior bleeds is the
Sphenopalatine artery,
which is a terminal division of the internal maxillary artery (branch of the external carotid system)
ENT procedure kit should include
Nasal speculum
Bayonet forceps
Headlamp
Suction catheter
Cotton pledgets
0.05% oxymetazoline
4% lidocaine solutions
Silver nitrate swabs
Some combination of absorbable and nonabsorbable materials for packing
Diagnosis of posterior hemorrhage
Generally, the diagnosis of posterior hemorrhage is only made in the ED once measures to control anterior bleeding have failed
hypertension in epistaxis
Rapid reduction of blood pressure during an episode of acute epistaxis is generally not advised.
In uncontrolled epistaxis requiring packing or surgical intervention, gentle reduction of persistent hypertension reduces hydrostatic pressure and theraby may aid clot formation
First step in direct nasal pressure
Ask the patient to blow the nose to expel clots to prepare mucosa for topical vasoconstrictors
Initial measures that are often sufficient to achieve hemostasis and facilitate further examination by anterior rhinoscopy
Instill a topical vasoconstrictor, such as oxymetazoline or phenylephrine
The patient should lean forward in the “sniffing” position and pinch the soft nares between the thumb and the middle finger for a full 10 to 15 minutes and breathe through the mouth
When is chemical cuaterization done
if two attempts at direct pressure have failed, chemical cauterization with silver nitrate is the next appropraite step for mild bleeding
Do NOT attempt chemical cautery unless
the bleeding vessel is visualized.
Electrical *cautery should be left to the otolaryngoloist due to the risk of septal perforation
Silver nitrate requires a
relatively bloodless field as the chemical reaction leading to precipitation of silver metal and tissue coagulation cannot proceed in the setting of active hemorrhage due to washout of substrate
you may use suction to help visualize the source of the bleeding
Once a relatively bloodless field is achieved, gently and briefly (a few seconds) apply silver nitrate directly to the bleeding site
Chemical cautery should NEVER be attempted on
both sides of the nasal septum
Subsequent attempts on the same side of the nasal septum should be separated by 4 to 6 weeks to avoid perforation
Examples of thrombogenic foams and gels
When are they used?
Oxidized cellulose (Gelfoam® and Surgicel®)
Gelatin matrix (FloSeal®)
These are considered after attempts have failed or in place of chemical cautery or insertoin of nasal tampons
Options in administering nasal tranexamic acid
Option 1:
200 mg (100mg/mL concentration) atomized into the affected nostril
Option 2:
cotton pledget or nasal tampon saturated with 500 mg of tranexamic acid and placed into the affected nostril
Option 3:
500 mg of tranexamic acid diluted with 5cc of NS and atomized into the affected nostril
When to perform anterior nasal packing
if direct pressure, vasoconstrictors, chemical cautery, are unsuccessful
and if thrombotic foams and gels are not available
Anterior packing can be created by
layering ribbon gauze in the nasal cavity
Remarks on anterior epistaxis balloons
Easy to use and more comfortable for the patient than layered strip gauze or nasal sponges
Coated with cellulose or other materials that promote platelet aggregation
Do NOT inflate with saline; if a saline-filled balloon ruptures, aspiration could result
Lengths of preformed nasal tampons or sponges
5-cm for anterior packing
10-cm for posterior packing
Merocel®
Key to placement of a ribboned gauze is
to lay the packing into he nasal cavity in an accordion-like manner so that part of each layer of packing lies anteriorly, preventing the gauze from falling posteriorly into the nasopharnyx
Posterior packing is associated with higher complication rates, including
pressure necrosis
infection
hypoxia
cardiac dysrhythmias, especially in patients with underlying cardiopulmonary disease, and thus, posterior packing is generally applied as a temporizing measure while awaiting ENT support
All posterior packing should be accompanied by
an anterior pack
If resources are limited, a satisfactory posterior pack can be achieved using a
14F Foley catheter
How to perform postetrior packing with Foley catheter
- Place the patient in “sniffing position”
- Anesthetize the nasal mucosa by placing three cotton pledgets soaked in a 1:1 mixture of 4% lidocaine solution and 0.05% oxymgetazoline intranasally for 5 minutes
- Consider cutting off the Foley tip beyond the balloon as the tip may stimulate the gag reflex
- Lubricate the distal third of the catheter with lidocaine gel and advance the Foley catheter along the floor of the nasal cavity until the end is visualized in the posterior oropharnyx
- Infalte the balloon with 7 mL of air, and gently retract the catheter approximately 2 to 3 cm until it is lodged in the choanal arch of the posterior nasopharynx
Precautions in posterior packing with Foley catheter
Do NOT use saline for balloon insulfation to prevent aspiraiton
May repeat insufflation with up to 10 mL of air. any more may risk development of pressure necrosis
Dispo for anterior epistaxis
If hemodynamic stability is ensured over a period of observation (1 hour or more in the ED), patient can be discharged with primary care or ENT follow up within 48 to 72 horus for removal of nonbiodegradable packing
Provide patients with instructions for simple techniques to control repeat hemorrhage
and consider a short-term prescription of inhaled vasoconstrictors such as oxymetazoline for rebleeding
