Management of Management of EpistaxisEpistaxis

Tom Hamilton, D.O.Tom Hamilton, D.O.

OtolaryngologistOtolaryngologist

Tulsa, OKTulsa, OK

The BasicsThe Basics

Epistaxis

History Physical Exam Treatment Plan

HistoryHistory

• OnsetOnset• Duration of bleedingDuration of bleeding• Amount?Amount?• LocationLocation• MEDICATIONSMEDICATIONS• Comorbidities: HTN, Smoker, Nose Comorbidities: HTN, Smoker, Nose

pickerpicker

EtiologyEtiology

• Unknown (most common)Unknown (most common)

• Trauma: MVA, Altercation, DigitalTrauma: MVA, Altercation, Digital

• CoagulopathyCoagulopathy

Physical ExamPhysical Exam

• Vital SignsVital Signs• LabsLabs• Position and prepare patientPosition and prepare patient• EquipmentEquipment• AnatomyAnatomy

Vitals and LabsVitals and Labs

• Airway #1Airway #1• Blood PressureBlood Pressure• CBCCBC• PT/INRPT/INR• PTTPTT

Position and PreparePosition and Prepare

• Sit patient upSit patient up• NEVER stand in front NEVER stand in front

of patient!!!!!!!!!of patient!!!!!!!!!• Universal Universal

precautionsprecautions• Have patient blow Have patient blow

nosenose• Always keep patient Always keep patient

either straight up or either straight up or slightly forwardslightly forward

EquipmentEquipment

• Headlight (ideal)Headlight (ideal)• Nasal SpeculumNasal Speculum• Afrin or Afrin/Pontocaine solution Afrin or Afrin/Pontocaine solution

(1:1)(1:1)• Cocaine (if you can get it)Cocaine (if you can get it)• Silver Nitrate sticksSilver Nitrate sticks• Nasal tamponNasal tampon• Nasal balloonNasal balloon• ExtrasExtras

HeadlightHeadlight

Nasal SpeculumNasal Speculum

Silver NitrateSilver Nitrate

Nasal TamponsNasal Tampons

Nasal BalloonsNasal Balloons

Helpful ExtrasHelpful Extras

• Bayonet ForcepsBayonet Forceps• Frazier suctionFrazier suction• Tongue DepressorsTongue Depressors

Physical ExamPhysical Exam

• Must evacuate Must evacuate clots first!clots first!

• Anterior or Anterior or PosteriorPosterior

• Areas that have Areas that have stopped will show stopped will show up as a small red up as a small red spot on the mucosaspot on the mucosa

• May have large May have large clot in oropharynxclot in oropharynx

Nasal AnatomyNasal Anatomy

• Anteriorly Anteriorly Kesselbachs PlexusKesselbachs Plexus

• Posteriorly Posteriorly Sphenopalatine Sphenopalatine ComplexComplex

• Inferior TurbinatesInferior Turbinates• SeptumSeptum

Treatment for Anterior Treatment for Anterior BleedBleed

• Use topical vasoconstrictor and hold Use topical vasoconstrictor and hold pressure for 15 minutes.pressure for 15 minutes.

Treatment for Anterior Treatment for Anterior BleedBleed

• If still bleeding and area identifiable, If still bleeding and area identifiable, cauterize with silver nitrate.cauterize with silver nitrate.

• After cautery, hold pressure again After cautery, hold pressure again for 10-15 minutes.for 10-15 minutes.

• If bleeding stops, pt can go home If bleeding stops, pt can go home with saline nasal spray QID for 7 with saline nasal spray QID for 7 days.days.

Treatment for Anterior Treatment for Anterior BleedBleed

• If still bleeding…..If still bleeding…..

Treatment for Anterior Treatment for Anterior BleedBleed

• And, if still bleeding…….And, if still bleeding…….

Wait after pack placed Wait after pack placed

10 minutes 10 minutes

Treatment for Posterior Treatment for Posterior BleedBleed

• Usually after a short anterior pack Usually after a short anterior pack has been placed with no identified has been placed with no identified location.location.

• Most anterior packs will cover both Most anterior packs will cover both sites, so it is better to use a longer sites, so it is better to use a longer tampon or balloon.tampon or balloon.

• Balloon device is most often Balloon device is most often successfulsuccessful

• Rarely place a true posterior packRarely place a true posterior pack

Old School Posterior Old School Posterior PackPack

Admission CriteriaAdmission Criteria

• Bilateral packsBilateral packs• Posterior packPosterior pack• Sleep ApneaSleep Apnea• Comorbid conditionsComorbid conditions

– Age over 40Age over 40– Pulmonary or cardiovascular diseasePulmonary or cardiovascular disease

After CareAfter Care

• Arrange follow up Arrange follow up within 2-3 days for within 2-3 days for pack removalpack removal

• Light activity onlyLight activity only• Saline nasal spray Saline nasal spray

to keep pack moistto keep pack moist• Anti Staph Anti Staph

antibioticsantibiotics

(Toxic Shock)(Toxic Shock)

It just won’t stopIt just won’t stop

• ENT ConsultENT Consult• Interventional Radiology Interventional Radiology • Surgical ControlSurgical Control

Questions?Questions?