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REASONS FOR
EXCESSIVE BLEEDING
Vascularity of nose
Both external and internal carotids.
Anastomosis between arteries and veins.
Blood vessels run just under the
mucosa-unprotected.
Larger vessels on the turbinate run in
bony canals- cannot contract.
Kiesselbachs Plexus
a.k.a
Littles
area
1/2 inch
from the caudal border of
the septum antero-inferiorly.
Vessels anastomosing are; Anterior
ethmoid, greater palatine, and
sphenopalatine, and septal branch
of superior labial.
Kisselbachs Plexus
Underlying Causes
Local irritation
Use of ASA or NSAIDS
Hypertension
Coagulapathies / Bleeding disorders
Platelet dysfunction
Underlying Causes
Allergies
Malignancy
Systemic disease such as granulomatous
disease(Wegeners sarcoidosis)
Hereditary hemorrhagic
telangiectasia(Osler-Weber-Rendu
syndrome)
Cirrhosis, Renal Failure
skull
Barotrauma
Local Factors
Cold, dry airmore common in wintertime
Dry heat
Nasal oxygen
Anatomic abnormalities
Atrophic rhinitis
Nasal septal deviation
Nasal septal perforation
Initial Management
ABCs
Medical history/Medications
Vital signsneed IV?
Physical exam
Anterior rhinoscopy
Endoscopic rhinoscopy
Laboratory exam
Radiologic studies
Laboratory Studies
CBC
PT / PTT
Bleeding Time
14
Treatment
IV Access
IV Fluids
Blood or Blood product transfusion
Control of hypertension
Correct coagulapathy
FFP, Vit. K, Protamine
Basic Treatment
Make the patient sit up, pinch nose,
water
16
side of bleeding
Which side did it start on
Was in coming out the front or draining
down the throat
Nosebleeds rarely have bilateral sources
Anterior or Posterior
Anterior
Bright
Treatment
Be Prepared
Adequate equipment to the bedside
Headlight
Nasal
Speculum
Suction
Packs
Cautery
Anesthetic
19
Treatment
Locate the point after packing the nose
CAUTERIZATION
Chemicals
Silver Nitrate stick
Electrical
Bovie
Bipolar
cautery
22
Nasal packs
Anterior nasal packs
Merocel Nasal Tampon
Vaseline Gauze
Inflatable Packs
Surgicel or Gelfoam
Posterior Epistaxis
Packing
Posterior Epistaxis
Packing
Epistaxis - Complications
Sinusitis
Possibility of airway obstruction
Toxic shock syndrome
Septal hematoma or abscess
Septal perforation
Loose pack obstructing the airway
Nasal scarring or stenosis
Alar necrosis
ICU Admit
Other Treatments
Surgery / embolization
Indications
Continued bleeding with packing
Required transfusion
Nasal anomaly precluding packing
Patient intolerance to packing
Posterior bleed vs. failed medical
Surgery
Ligation of vessels
Maxillary artery
Ethmoid arteries
External Carotid artery
Transmaxillary artery
ligation
Electrocautery of posterior wall before
removal
Microscopic dissection and ligation of IMA
--descending palatine & sphenopalantine most
important
Recurrence rate (failure rate) of 10-15%
Complication rate of 25-30% (oa
fistula,dental, n)
Imax ligation now done commonly through
endoscopic approach
Transnasal Endoscopic
Sphenopalatine
Artery
Follow Middle Turbinate to posteriormost
aspect
ligation
Vertical mucoperiosteal incision 7-8mm
ECA ligation
Effectiveness
Anterior border of SCM
ID ECA/ICA
Ligation after clear that surrounding
Selective
Angiography/embolization
Helps identify location of bleeding
Embolization most effective in patients who
Still bleeding after surgical arterial ligation
Bleeding site difficult to reach surgically
Comorbidities prohibit general anesthetic
bleed
Treatment after
Discharge
Humidity/emolients
Discontinue offending meds
Nasal saline sprays
Avoidance of nose picking/blowing
Sneeze with mouth open
Avoid straining/bedrest
Refrences
Textbook of E.N.T by Dr. Dhingra
Essentials of E.N.T by Dr. Hazarika
Textbook of E.N.T by Dr. Mohan Bansal
Self Assesment AIPGME by Dr. Arvind Arora