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epistaxis. DEPARTMENT OF OTORHINOLARYNGOLOGY – HEAD&NECK SURGERY PADJADJARAN UNIVERSITY/ HASAN SADIKIN HOSPITAL BANDUNG. INTRODUCTION. EPISTAXIS Any bleeding from the nose caused by haemostatic disturbance Haemostatic abnormality Mucous abnormality Vascular pathology - PowerPoint PPT Presentation
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EPISTAXIS
DEPARTMENT OF OTORHINOLARYNGOLOGY
– HEAD&NECK SURGERYPADJADJARAN
UNIVERSITY/ HASAN SADIKIN HOSPITAL
BANDUNG
INTRODUCTIONEPISTAXIS Any bleeding from the nose caused
by haemostatic disturbance
Haemostatic abnormality•Mucous abnormality•Vascular pathology•Coagulation disorders
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EPIDEMIOLOGY Prevalens: 7% - 14%. Recurrence
4%. Age : < 10 , > 35Based on source of bleeding :
Anterior epistaxis esp. child – young adult
Posterior epistaxis old ageCold climate and low humidity >>
DRYNESS
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ANATOMY A. Carotis Eksterna
A. MaksilarisA. Fasialis
A. Carotis InternaA. Oftalmika A. Ethmoidales
anterior & posterior
5Adapted from : Netter Atlas
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CLASSIFICATION
Anterior epistaxis : occurs primarily in the Little’s area
(Kiesselbah’s plexus) and more often venous in origin.
Posterior epistaxis : primarily in the region of the posterior septum, posterior lateral nasal wall (Woodruff’s
nasopharyngeal plexus) & posterior septum more often arterial in origin
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ETIOLOGYLOCAL
Trauma: digital, fractures
Nasal sprays Inflammatory
reactions Anatomic
deformities Foreign bodies Intranasal tumors Chemical inhalants Nasal prong O2,
CPAP Surgery
SYSTEMIC Hypertension Vascular
disorders Blood dyscrasias Hematologic
malignancies Allergies Malnutrition Alcohol Drugs (aspirin,
etc) Liver / renal
disease
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EVALUATION
INITIAL : COMPRESSION OF THE NOSTRIL (5-20 MIN)
PLUGGING WITH GAUZE OR COTTON SOAKED IN TOPICAL ANESTHETIC – DECONGESTAN
TILTING HEAD FORWARD PREVENTS POOLING BLOOD TO POSTERIOR PHARYNX AVOIDING NAUSEA & OBSTRUCTION
SECURING HEMODYNAMIC STABILITY & AIRWAY PATENCY FLUID RESUSCITATION
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EVALUATION NO RESPOND LOCATE THE SOURCE OF BLEEDING : ANTERIOR RHINOSCOPY / NASOENDOSCOPY
WITH PROPER LIGHT SOURCE & INSTRUMENT
SELF PROTECTION
REDUCE THE ANXIETY
A THROUGH HISTORY SHOULD BE TAKEN WITH ATTENTION TO DURATION, FREQUENCY, SEVERITY FAMILY HISTORY / BLEEDING DISORDER?
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INSTRUMENT
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PHYSICALEXAMINATION• General status• Local status
Determine : - Anterior or
posterior - Other stigmata
MANAGEMENT AIMED
Stop the bleedingAvoid complicationAvoid recurrence
Most anterior epistaxis self limitedControlled by pinching ala nasi 5 – 20
min
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Minor Hemorrhagestop spontaneously pediatric population, > 64% having experienced epistaxis
Antiseptic creamBarrier agent
Anterior nasalpackingRemoved after 20 men
Silver nitrat cauteryElectric cautery
MANAGEMENT
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Major Hemorrhage Emergency active epistaxis
Ensure adequate iv access & resuscitation
•Blood cloots out of his or her nose•Explore with speculum or nasal endoscopy and suction
• Anterior bleeders ant nasal pack or cautery
•Posterior bleeders post nasal pack arterial ligation or embolization is performed
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MANAGEMENT
DIFFUSE / OOZING, MULTIPLE BLEEDING SITE OR RECURRENT BLLEDING INDICATE SYSTEMIC PROCESS
HEMATOLOGIC EVALUATION
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MANAGEMENT•TRADITIONAL•Ribbon gauze with
vaselin / antibiotic oinment
•OTHERS•Non absorbable•Absorbable
NASAL PACKIN
Ganterior
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Anterior Nasal Packing
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MANAGEMENT
NASALPACKING
POSTERIOR
BELLOCQ TAMPONFOLEY CATHETERBALLOON PACK
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Posterior Nasal Packing (Bellocq tampon)
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Balloon Pack
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SURGERY
LIGATION A. ETHMOIDALES ANTERIOR A. MAXILLARIS A. SPHENOPALATINA A. CAROTID EXTERNA
EMBOLIZATIONSEPTAL DERMOPLASTY,
SEPTOPLASTY
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AVOID COMPLICATIONCOMPLICATION
HYPOVOLEMIC SHOCK APNEA, HYPOXIA SEPTAL PERFORATION
ALAR RIM, COLUMELLA NECROSIS, LASERATION PALATUM MOLLE / LIPS
ASPIRATION RECALCITRANT
BLEEDING INFECTION
AVOIDANCE IV FLUID MONITOR O2 LIMITED CAUTERY,
PROPER PACK SIZE STABILIZATION PACKING
WITHOUT CONTACT WITH ALAR / COLUMELLA
ADEQUATE PLACEMENT & SECURING NASAL PACKS
PROPHYLACTIC ANTIBIOTICS
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AVOID RECURRENCE
Patient education Avoidance of digital manipulation,airborne irritants, dander, smoke
Keep the nose moistControl of allergies Tappering amount of nasal spray Intranasal surgical technical
refinements
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SUMMARY GOOD EVALUATION & HISTORY PREPARATION &
PLANNING
PROPER INSTRUMENTATION
DON’T PANIC !
MANAGEMENT : CONSERVATIVE, COMFORTABLE, IF FAILED SURGERY
AVOID COMPLICATION FROM BLEEDING & OR MANAGMENT
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ANTERIOR NASAL PACKING PROCEDURE
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LEARNING GUIDE: ANTERIOR NASAL PACKING PROCEDURE
No Procedures
Performance Scale
0 1 2 3
Preparation
1 Greet the patient respect fully and with kindness introduce yourself.
2 The patient should be given adequate explanation about examinations.
3 Explain the goals or the expected result examination.Check the instrument& material.
Procedures
4 Hold the nasal speculum with one hand and then put in on the left or right nostril
5 Holt it with the thumb on the joint, the index finger free to steady it on the patient’s nose and the rest of the fingers on the stem proper to hold the speculum
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6 Always try to open the stem or times in an upward action and not down into the floor or the nose. The good view of the nose anteriorly can be obtained simply by pressing on the tip of the nose
7 Topical anesthesia can be administered in order to decreasing discomfort, the risk of apnea, bradycardia, and hypotension by blocking the nasal-vagal reflex. A pledget or cotton swab soaked in 1 % pantocaine or lidocaine solution (with or without containing 1-2 drops of an epinephrine solution dilutes 1:1,000) is placed in the nose for 3-5 minutes
8 The traditional anterior pack petrolatum gauze (0.5 x 72 inch) coated with an antibacterial ointment is firmly packed into the nasal cavity
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9 The packing is placed in a methodical (layering) fashion toward the posterior choana, starting at the nasal floor and packing up to about the level middle turbinate. It is possible to put a large amount into each side
10 Great care must be taken that :- The pack does not rub on the columella, which is easily traumatized- The free and of the packing should not be visible in the oropharynx behind the soft palate as this can lead to irritation, and also a danger that this portion might slip deeper into the aerodigestive tract and cause complication
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11 Once the gauze is firmly packed properly into the nasal cavity:- The patient should be admitted and kept under careful observation - Give the patient humidifies oxygen and sedate with caution and only with reversible agents- As the pack will be left in for at least 48 hours, put the patient on a board-spectrum antibiotic- Establish an intravenous line, and cross-match the blood
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