Académique Documents
Professionnel Documents
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Maj Dr BB Khatri
Dept of ENT & HNS
SBH and NAIHS
EPISTAXIS
Clinical Case
60/f
Spontaneous nose bleed
ER management
Endoscopy
Packing
Removal of pack: rebleed
Cauterised
EPISTAXIS
FLANGES FRAMEWORK
ROOM CAVITY
SCROLLS
BLOOD SUPPLY
Medial wall Lateral wall
Spheno
palatine
A Br
Facial A
BLOOD SUPPLY
ANT ETHMOID ARTERY
PECULIARITIES
POST ETHMOID ART
DUAL BLOOD
SUPPLY
SPHENO
LITTLES AREA
PALATINE ERECTILE TISSUE
ART
LITTLES AREA
KEISSELBACHS
PLEXUS
GREATER
PALATINE Woodrofs area
SUPERIOR ART
LABIAL ART
BLOOD SUPPLY
Predominantly- ECA.
Retrocollumellar venous
bleeding can be significant.
TYPES OF EPISTAXIS
ANTERIOR POSTERIOR
More common Less common
Site generally Littles Postero- superior, difficult
area or antero-lat wall. to localise
Age generally > 40 yrs
children/ young
Cause commonly Spontaneous
trauma. hypertension/
Bleeding mild, local arteriosclerosis
pressure/ ant pack Severe, both ant/ post
suffice packs may be reqd.
APPROACH TO EPISTAXIS
Quick evaluation
Resuscitate
Arrest Bleeding
General look
Air Hunger - Tachypnoea
Pulse Tachycardia
BP Hypotension/ Hypertension
Active Bleeding?
Anterior
Posterior
Any evidence of a generalized bleed?
RESUSCITATION
Anxiolytics
IV Lifeline
Blood for grouping
& PCV
IV Fluids
Blood transfusion
STOP BLEEDING
ER ROOM
ENT CENTRE
ADVANCED CENTRES
STOP BLEEDING MI ROOM
ER ROOM
ENT CENTRE
ADVANCED CENTRES
STOP BLEEDING ENT CENTRE
VISUALISE THE
SITE OF BLEED
Ant & Post
Rhinoscopy
Nasal Endoscopy
ARREST BLEEDING
CAUTERISATION
ANTERIOR NASAL
PACKING
POSTERIOR NASAL
PACKING
MANAGEMENT
ANTERIOR NASAL PACKING
Topical Anaesthesia
Nasal Speculum
Tilleys Forceps
Illumination
Suction
ANTERIOR NASAL PACKING
Topical / General
Anaesthesia
Nasal Speculum
Tilleys Forceps
Red Rubber Catheters
Illumination
Suction
POSTERIOR NASAL PACKING
ALTERNATIVES TO PACKING
Merocel
Foleys catheter
12/14Fr
Epistaxis catheters
STOP BLEEDING
ER ROOM
ENT CENTRE
ADVANCED CENTRES
STOP BLEEDING ADVANCED
CENTRES
Angiography & DSA
Arterial Ligation
Ethmoidal vessels medial orbital incision
Maxillary artery Caldwell Lucs approach
ECA ligation if required
Embolisation
Gel sponge/beads/desiccated dura
In severe recurrent bleeds
Embolisation of ICA branches dangerous
Embolise and then ligate
Rare treatments for haemorrhagic telangiectasia
FIND & TREAT THE CAUSE
- LOCAL CAUSES
Trauma
Hard blowing/ sneezing.
Nose picking
#s of nose/ maxillo-facial region
Infections
Acute
URTIs
Sinusitis
Vestibulitis
Chroniconic
Atrophic rhinitis
Rh sicca
Granulomata - TB, Syphilis, Rhinosporiodiosis.
Foreign Bodies
DNS, Polypi.
Tumours
Juvenile nasopharyngeal angiofibroma (JNA)
Others papilloma,haemangioma,Carcinoma
FIND & TREAT THE CAUSE
- GENERAL CAUSES
HYPERTENSION
BLEEDING DISORDERS Coagulopathies/ Thrombopathies
SYSTEMIC DISORDERS Renal/ Liver
DRUG INDUCED
ENVIRONMENTAL High altitude, dry weather.
IDIOPATHIC
CONGENITAL- Oslers disease
BLOOD STAINED RHINORRHEA IN HEAD
INJURY