Management of Epistaxis Tom Hamilton, D.O. Otolaryngologist Tulsa, OK

The Basics

History OnsetOnset Duration of bleedingDuration of bleeding Amount?Amount? LocationLocation MEDICATIONSMEDICATIONS Comorbidities: HTN, Smoker, Nose pickerComorbidities: HTN, Smoker, Nose picker

Etiology Unknown (most common)Unknown (most common) Trauma: MVA, Altercation, DigitalTrauma: MVA, Altercation, Digital CoagulopathyCoagulopathy

Physical Exam Vital SignsVital Signs LabsLabs Position and prepare patientPosition and prepare patient EquipmentEquipment AnatomyAnatomy

Vitals and Labs Airway #1Airway #1 Blood PressureBlood Pressure CBCCBC PT/INRPT/INR PTTPTT

Position and Prepare Sit patient up NEVER stand in front of patient!!!!!!!!! Universal precautions Have patient blow nose Always keep patient either straight up or slightly forward

Equipment Headlight (ideal)Headlight (ideal) Nasal SpeculumNasal Speculum Afrin or Afrin/Pontocaine solution (1:1)Afrin or Afrin/Pontocaine solution (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

Headlight

Nasal Speculum

Silver Nitrate

Nasal Tampons

Nasal Balloons

Helpful Extras Bayonet ForcepsBayonet Forceps Frazier suctionFrazier suction Tongue DepressorsTongue Depressors

Physical Exam Must evacuate clots first!Must evacuate clots first! Anterior or PosteriorAnterior or Posterior Areas that have stopped will show up as a small red spot on the mucosaAreas that have stopped will show up as a small red spot on the mucosa May have large clot in oropharynxMay have large clot in oropharynx

Nasal Anatomy Anteriorly Kesselbachs PlexusAnteriorly Kesselbachs Plexus Posteriorly Sphenopalatine ComplexPosteriorly Sphenopalatine Complex Inferior TurbinatesInferior Turbinates SeptumSeptum

Treatment for Anterior Bleed Use topical vasoconstrictor and hold pressure for 15 minutes.Use topical vasoconstrictor and hold pressure for 15 minutes.

Treatment for Anterior Bleed If still bleeding and area identifiable, cauterize with silver nitrate.If still bleeding and area identifiable, cauterize with silver nitrate. After cautery, hold pressure again for minutes.After cautery, hold pressure again for minutes. If bleeding stops, pt can go home with saline nasal spray QID for 7 days.If bleeding stops, pt can go home with saline nasal spray QID for 7 days.

Treatment for Anterior Bleed If still bleeding…..If still bleeding…..

Treatment for Anterior Bleed And, if still bleeding…….And, if still bleeding……. Wait after pack placed 10 minutes

Treatment for Posterior Bleed Usually after a short anterior pack has been placed with no identified location.Usually after a short anterior pack has been placed with no identified location. Most anterior packs will cover both sites, so it is better to use a longer tampon or balloon.Most anterior packs will cover both sites, so it is better to use a longer tampon or balloon. Balloon device is most often successfulBalloon device is most often successful Rarely place a true posterior packRarely place a true posterior pack

Old School Posterior Pack

Admission Criteria Bilateral packsBilateral packs Posterior packPosterior pack Sleep ApneaSleep Apnea Comorbid conditions Comorbid conditions –Age over 40 –Pulmonary or cardiovascular disease

After Care Arrange follow up within 2-3 days for pack removalArrange follow up within 2-3 days for pack removal Light activity onlyLight activity only Saline nasal spray to keep pack moistSaline nasal spray to keep pack moist Anti Staph antibioticsAnti Staph antibiotics (Toxic Shock) (Toxic Shock)

It just won’t stop ENT ConsultENT Consult Interventional RadiologyInterventional Radiology Surgical ControlSurgical Control

Questions?