1. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 1 EPISTAXIS Don Hudson, D.O., FACEP/ACOEP Reviewed & Presented for training

2. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 2 REASONS FOR EXCESSIVE BLEEDING u Vascularity of nose u Both external and internal carotids. u Anastomsis between arteries and veins. u Blood vessels run just under the mucosa- unprotected. u Larger vessels on the turbinate run in bony canals- cannot contract.

3. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 3 LITTLE'S ( KIESSELBACH'S) AREA  1/2 inch from the caudal border of the septum antero-inferiorly.  Vessels anastomosing are; Anterior ethmoid, greater palatine, and sphenopalatine, and septal branch of superior labial.  Bleeding may be arterial or venous.

4. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 4 Lateral Wall Frank Netter. Ciba

5. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 5 Blood supply Septum Frank Netter. Ciba

6. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 6 Little’s area u Confluence of : –Anterior Ethmoidal a. –Greater Palatine a. –Sphenopalatine a. –Sup. Labial a.

7. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 7 CLASSIFICATION

8. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 8 I. According to site u Anterior u Superior; Anterior ethmoid ( bleeding is from above ant. half of middle turbinate) u Inferior; Greater palatine, u Posterior; Sphenopalatine (Bleeding is from below anterior half of middle turbinate

9. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 9 II. PRIMARY & SECONDARY

10. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 10 III. According to Etiology u Local Causes: [1] Trauma –Nose picking, –fractures.

11. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 11 LOCAL CAUSES [2] Infections: u Viral:Influenza, measles u Diphtheria, u lupus vulgaris, leprosy, u Parasites, maggots, u fungal

12. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 12 LOCAL CAUSES [3] Idiopathic: u Wegner's granulomatosis, u Osler-Weber-Rendau's syn., u atrophic rhinitis

13. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 13 LOCAL CAUSES [4] Neoplasms: Of the – nose, – nasopharynx and –sinuses. Angiofibroma Carcinom of the Nasopharynx

14. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 14 Local Causes [4] Miscellaneous: u Septal spur, u foreign bodies

15. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 15 General Causes u Hypertension, u CCF, mitral stenosis, u Cirrhosis, u coagulopathies, u anemias, purpura, leukemias,

16. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 16 General Causes u Malignancies, u Caissons' disease, u Endometriosis, u Nephritis, u Typhoid

17. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 17 IV. According to Age u Children; –Foreign body, nose picking, nasal diphtheria. u Adults: –Trauma, idiopathic. u Middle age: – tumors. u Old age: –hypertension.

18. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 18 MANAGEMENT I] Investigations: u CBC, u Bleeding profile, BT, CT, PT, APTT, Platelets u Hb.

19. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 19 II. TREATMENT u First aid u Definitive treatment u Prevention of recurrences

20. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 20 FIRST AID – Make the patient sit up, pinch nose, open mouth and breath. – Ice on fore head.

21. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 21 DEFINITIVE TREATMENT u Look into the nose. u Assess blood loss. –Crystalloids or colloids –Transfusion u Locate the point after packing the nose with 4% xylocaine and 1:1000 adrenaline mixture

22. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 22 CAUTERIZATION 1) Chemicals; u Silver Nitrate stick, chromic acid bead. 2) Electrical  Apply ointment and advise against blowing and nose picking.

23. ANTERIOR PACKING u Unable to control bleeding. u Ribbon, tampon, splints. u BIPP, Polyfax

24. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 24

25. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 25

26. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 26 POSTERIOR PACKING u Posterior packing if bleed is posterior. u GA. u Foley's or other inflatable devices u Removed as soon as possible. u Antibiotics. u Transfuse. u Blood gases in children.

27. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 27 Complications u Infection, u loose pack obstructing airway.

28. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 28 SPECIAL CASES u Haemophilia; –Replace factor VIII, or fresh blood. u Other clotting deficiency; –FFP. u Purpura; – Platelets

29. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 29 SPECIAL CASES u Anticoagulants; –Stop drug, or titrate. –Heparin is reversed with protamine sulphate, –warfarin with vitamin K u Unconscious head injury; –Dangerous to pack in suspected skull #. u Telengiectasia; –Septodermoplasty.

30. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 30 OTHER TREATMENTS u Ligation of vessels –Maxillary artery –Ethmoid arteries –External Carotid artery

31. 4/99 Raza M. Jafri, FRCS docraza@khi.comsats.net.pk 31 OTHER TREATMENTS u Embolization u Catheters with iced water lavage u 2% lignocaine and adrenaline injection in greater palatine foramen