1. BY LIZ CHUI UCI T-RAP SS1 STUDENT PRESENTATION
Epistaxis
BY LIZ CHUI UCI T-RAP
SS1 STUDENT PRESENTATION

2. Background
Epistaxis is another name for what is commonly known as nose-bleeds
It is an acute hemorrhage from the nostril, nasal cavity, or nasopharynx
Common ED complaint, but 90% of patients can be treated with
Occurs up to 60% of general population, but rarely leads to massive bleeding and death

3. Anterior (more common)
Two sources
Anterior (more common)
Posterior (typically common among old patients)
Most cases of epistaxis occur in the anterior part of the nose, with the bleeding usually arises from the Kiesselbach’s plexus. Posterior epistaxis generally arises from the posterior nasal cavity via branches of the sphenopalatine arteries. Such bleeding usually occurs behind the posterior portion of the middle turbinate or at the posterior superior roof of the nasal cavity.
In most cases, anterior bleeding is clinically obvious. In contrast, posterior bleeding may be asymptomatic or may present insidiously as nausea, hematemesis, anemia, hemoptysis, or melena. Infrequently, larger vessels are involved in posterior epistaxis and can result in sudden, massive bleeding.
Where does it happen?

4. Causes
Many different causes – locally, systemically, and environmentally
Environmental causes include allergens and humidity
Can also be idiopathtic

5. Common local causes Chronic sinusitis
Epistaxis digitorum (nose picking)
Foreign bodies
Intranasal neoplasm or polyps
Irritants
Medications
Rhinitis
Trauma
- sinusitis: inflammation of the sinuses
- Neoplasm is an abnormal mass of tissue as a result of neoplasia. Neoplasia is the abnormal proliferation of cells
Rhinitis: stuffy nose, irritation and inflammation of some internal areas of the nose
Medications (e.g., topical corticosteroids)
Irritants (e.g., cigarette smoke)

6. Common systemic factors
Hemophilia
Hypertension
Leukemia
Liver disease (e.g., cirrhosis)
Medications
Platelet dysfunction/Thrombocytopenia
Systemic (spread system wide)
Leukemia: lack of blood platelets
Hemophilia refers to a group of bleeding disorders in which it takes a long time for the blood to clot.
Platelet helps blood clot/Thrombocytopenia is any disorder in which there are not enough platelets.
Hypertension - Uncontrolled high blood pressure makes highly vascularized areas (including the nose) prone to bleeding.
Medications – Medications that interfere with blood clotting, such as anticoagulants and non-steroidal anti-inflammatory drugs can make it easy for a nose to bleed. (e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory drugs)

7. Treatment Flow of blood normally stops when the blood clots
To encourage blood clotting
Pinch the upper fleshy part of nose
Do so for 5-20 minutes
Tilt head forward can decrease the chance of nausea and airway obstruction from swallowing blood
Vasoconstrictive agents can also be used
Other products available to promote coagulation

8. Packing when simple treatment fails for anterior bleeding
Anterior nasal cavity is packed from posterior to anterior with ribbon gauze that has petroleum jelly
Bayonet forceps and a nasal speculum can be used to approximate accordion folding of gauze
Each layer should be pressed down firmly before next layer is added
Bayonet forceps
Nasal speculum
Packing of the anterior nasal cavity using gauze strip impregnated with petroleum jelly. A. Gauze is gripped with bayonet forceps and inserted into the anterior nasal cavity. B. With a nasal speculum, the first packing layer is inserted along the floor of the anterior nasal cavity. Forceps and speculum then are withdrawn. C. Additional layers of packing are added in an accordion-fold fashion, with the nasal speculum used to hold the positioned layers down while a new layer is inserted. Packing is continued until the anterior nasal cavity is filled.
Packing should be removed in hours
Packing when simple treatment fails for anterior bleeding

9. Packing for posterior epitasis
Done by Otolaryngologist
A catheter is passed through the nostril and through the nasopharynx and out the mouth
A gauze pack is at the end of the catheter
The gauze pack is guide through the mouth and into the posterior nasal cavity
Posterior nasal packing. A.
After adequate anesthesia has been obtained, a catheter is passed through the affected nostril and through the nasopharynx, and drawn out the mouth with the aid of ring forceps.
B. A gauze pack is secured to the end of the catheter using umbilical tape or suture material, with long tails left to protrude from the mouth.
C. The gauze pack is guided through the mouth and around the soft palate using a combination of careful traction on the catheter and pushing with a gloved finger. This is the most uncomfortable (and most dangerous) part of the procedure; it should be completed smoothly and with the aid of a bite block (not shown) to protect the physician’s finger.
D. The gauze pack should come to rest in the posterior nasal cavity. It is secured in position by maintaining tension on the catheter with a padded clamp or firm gauze roll placed anterior to the nostril. The ties protruding from the mouth, which will be used to remove the pack, are taped to the patient’s cheek.
Packing for posterior epitasis

10. Other treatments Balloon packing Cauterization of blood vessel
Laser therapy
Embolization
Balloon packing: balloon is inflated with saline and sits in the posterior nasal cavity
Doctor may use an endoscope to find the blood vessel needing cauterization. A chemical may be used such as silver nitrate
Laser therapy: a laser beam seals the bleeding blood vessel
Embolization: a special plug inserted into the bleeding vessel blocks blood flow

11. Prevention Cooler house
Vaporizer to return humidity and moisture to the air
Nasal saline spray and water soluable jelly (especially for winter months)
Avoid picking the nose or blowing the nose too vigorously.
Do not strain to bend down or lift anything too heavy.
Dryness may result in crusting, cracking, and bleeding of the nasal membranes

12. References http://www.aafp.org/afp/2005/0115/p305.html