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Epistaxis definition, causes, first aid and management

Definition: Simply it is bleeding from the nose. or acute haemorrhage from nasal cavity, nostrils or even the nasopharynx. 
Etiology:

a. Local causes:

1. Idiopathic:
  • Commonest cause (90%).
  • May be precipitated by minor trauma or hot atmosphere.
  • Bleeding from little’s area (Kiesselbach’s plexus), which is the anterior part of the septum where septal branch of sphenopalatine, anterior ethmoidal, greater palatine & superior labial branch of facial artery anastomose, most site exposed to cold dry air and crustations.
    Epistaxis-bleeding-nose

2. Traumatic:
  • Foreign body, fracture nose, and fracture skull base.
  • Iatrogenic; Functional endoscopic sinus surgery, Septoplasty, Turbinate resection, Nasotracheal intubation and Nasogastric tube.

3. Inflammatory:
4. Neoplastic:
a) Tumors of the nose & sinuses:
- Benign: hemangioma - Malignant
b) Tumors of the nasopharynx:
- Benign: angiofibroma - Malignant: carcinoma & sarcoma.

  • Convex side angulated vessels
  • Concave side mucosal dryness
  • Septal perforation
6- Hereditary hemorrhagic telangiectasia.

b. General Causes:


1. Cardio-vascular causes:
  • High arterial pressure (hypertension): Commonest cause in elderly, usually it is posterior bleeding. Hypertension does not initiate but maintain bleeding.
  • High venous pressure: Heart failure, mitral stenosis, emphysema, or mediastinal masses.
2. Blood diseases:
Purpura, hemophilia, leukemia, thrombocytopenia.

3. Drugs
  • Anticoagulants, e.g. heparin. 
  • Antiplatelet e.g. aspirin, NSAID.
4. Hepatic
Liver failure >> hypoprothrombinemia.

5. Fever
E.g. Exanthemata: rheumatic fever & infective endocarditis >> vasculitis.

Management of Epistaxis : 

I- First Aid:

  1. Patient is managed in seated position with head slightly flexed and leaning forward unless shocked (supine with head down).
  2. Pinch the nose between index & thumb.
  3. Apply cold compresses to the forehead.
  4. Patient is asked to spit blood not to swallow it.
  5. Insert a piece of cotton soaked with a vasoconstrictor solution (Epinephrine 1/100, 1000) into nostrils for 5-10m. (avoided in hypertensive & cardiac patients).

II- Assessment:

a. History of the cause
b. Examination for: 
1. Site: Unilateral or bilateral, Anterior or posterior.
Sites: 
  • Little‘s area (90%).
  • Upper part above middle turbinate: (anterior, posterior ethmoidal >> (ICA).
  • Posterior part below middle turbinate: (Sphenopalatine >> ECA).
NB. Rigid endoscope may be used.

2. Severity.
3. Shock: Weak rapid pulse, hypotension, tachypnea, pallor, cold, sweating, Irritability, and low urine output.
4. Cause.

III- Control bleeding:

(A) Mild bleeding:
1. General first aid.
2. Cauterization:
  • When bleeding stops or diminishes.
  • Under: local A. 4% cocaine or xylocaine.
  • By: Electrical: more effective,  Chemical: silver nitrates or chromic acid.
  • Then: avoid manipulation, lubricant nasal drops for 1 week.
3. Nasal packing if bleeding continues after cautery.

(B) Severe bleeding:
Stop bleeding by packing + control shock
1. Anterior nasal packing:
  • Nasal packing can be used to control active bleeding as a tamponade using absorbable (as gelatin, carboxymethyl-cellulose, oxidized cellulose, hyaluronic acid, fibrillar collage) and nonabsorbable packs (as ribbon gauze, folly’s catheter, inflatable rubber tampon, or Mirocell) according to availability and clinician preference.
  • Original packing was a strip of ribbon gauze 50 X 2.5cm, impregnated with Vaseline, lignocaine & antibiotic ointment, apply surface anesthesia, introduced in layers.
  • Left for 24-48h.
  • Give antibiotics.
    packing-epistaxis
2. Posterior nasal packing:
  • If anterior packing fails to control bleeding.
  • Under general anasthesia.
  • Piece of gauze with antiseptic ointment lodged firmly in the nasopharynx with 2 threads coming from the nostrils & tied together and a third one coming from the mouth
  • Left for 24-48h.
  • Give antibiotics.
  • Alternatively: Foley’s catheter.
Epistaxis-management


3. General measures:
  • Coagulants e.g. vitamin k, fresh plasma. 
  • Antibiotics.
  • Sedation e.g. diazepam -Transfusion blood, fluids.
  • Rest in bed supine position.
  • Observation of vital signs, Hemoglobin %, blood gases &urine.

4. Arterial ligation:
If all previous measures failed, or recurrent epistaxis despite repeated packing.
  • Ethmoidal artery ligation via external frontoethmoidectomy approach or endoscopically (if bleeding coming from above middle turbinate).
  • Sphenopalatine artery ligation or cautery using endoscope.
  • Maxillary artery ligation Via transantral approach (if bleeding coming from below middle turbinate): more effective than ECA ligation.
  • ECA ligation.
    cauterization-epistaxis

5. Arterial embolization:
During angiography by gelfoam, polyvinyl alcohol or coiling.

IV- Management of the cause:

(A) Investigations:
  • Coagulation profile B.T, C.T, PT, PC, PTT.
  • Blood picture.
  • C.T & biopsy from a nasal mass.
(B) Treatment of the cause:
  • Bleeding from the little's area: it is usually controlled by cauterization either chemically using silver nitrates or electrocautery (N.B. don't cauterize two opposite sides of the septum to avoid septal perforation)
  • Hypertension: use antihypertensive drugs.
  • Tumors especially angiofibroma: endoscopic excision.
  • Deviated septum or septal perforation: septal surgery.
  • Hereditary hemorrhagic telangiectasia: laser photocoagulation, bipolar cauterization, systemic hormone therapy, or septodermoplasty.
  • Defect in coagulation: treat the cause.

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