Epistaxis

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Epistaxis

• Essie Fine
• August 2007

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Patient Profile

• The ER calls about a 60 year old man with
  epistaxis. They tell you that they have been
  trying to stop the bleeding for one hour,
  including placing a posterior pack on the left
  side and an anterior pack on the right side. He
  is continuing to bleed from the right side and is
  spitting out large clots of blood.

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You are twenty minutes away. What do you want to
ask over the phone?What supplies do you need?
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What do you want to know

• Airway
• Breathing
• Circulation

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What do you want to know?

• HPI Prior episodes, exacerbating factors, how
  did it start, which side did it start on,
  hematemesis
• PMH - Trauma, hypertension, bleeding disorders,
  cancer risk factors or history, rhinitis, renal
  failure, liver failure
• PSH nasal surgery, trauma
• Medications aspirin, plavix, warfarin, herbs
• Social history smoking, drinking, risk factors
  for CA
• Labs cbc, coags, chem 7, serial hct

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What supplies do you need?

• Headlight
• Nasal Endoscope
• Frasier tip suction
• Nasal speculum
• Saline
• Afrin, lidocaine, other anesthetics, needles and
  syringes
• Cotton pledgets
• Bayonet forceps
• Cautery, silver nitrate, or other
• Anterior and Posterior packing material (saline
  for the baloon, not air)
• Balloon for posterior pack commercial or foley
  catheter
• Umbilical clamp, gauze or eye pads
• Antibiotic ointment

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Packing materials

• Vaseline Gauze
• Merocel - polyvinylchloride
• Surgicel oxidized cellulose
• Gelfoam purified pork skin gelatin

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• While the subs intern is getting your supplies,
  you ponder the differential diagnosis of this
  condition, including pediatric causes of
  epistaxis.

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• V telangiectasia, vascular malformation, JNA
• I sinus surgery, medications, foreign body,
  atrophic rhinitis, o2 cannula, medications
• T septal fracture, septal perforation, septal
  deviation, nose picking, NG placement
• A thrombocytopenia, collagen vascular diseases,
  granulomatous diseases
• M liver failure, renal failure, bleeding
  disorder, hypertension, hypothermia
• I URI, allergic rhinitis, childhood exanthems,
  vestibulitis, non-allergic rhinitis, syphillis,
  TB
• N-Nasopharyngeal angiofibroma, pyogenic
  granuloma, papilloma, NPC, lethal midline
  granuloma, leukemia, lymphoma, rhabdomyosarcoma
• C Hereditary hemorrhagic telangiectasia,
  meningiocele, encephalocele

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Drugs!

• Thrombocytopenia chemotherapy, quinidine, sulfa
  preparations, H2 blockers, oral antidiabetic
  agents, gold salts, rifampin, heparin, alcohol
• Affecting coagulation pathway Warfarin, Heparin
• Affecting platelet function Aspirin,
  clopidogrel, nsaids
• Herbs that may cause bleeding Dong quai,
  Danshen, Feverfew, Garlic, Ginger, Gingko,
  Ginseng

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• As you drive in, you review the arterial supply
  to the nose, and you try to remember where the ER
  keeps face-shields and gowns.

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What is wrong with this picture? The anterior
and posterior ethmoidal come through the ethmoid
sinuses, not from the skull base.
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Anatomy

• ICA (branches of ophthalmic)
• Anterior ethmoid supplies lateral wall of nose,
  nasal septum, nasal tip
• Posterior ethmoid posterior lateral wall of
  nose, superior turbinate and sup septum
• ECA (branches of internal maxillary)
• sphenopalatine supplies the posterior septum,
  posterior middle and superior turbinates
• Descending palatine lower midseptum
• Superior labial (facial artery) anterior septum

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History

• Nose bleeding started suddenly from the right
  nostril after moving some boxes, 1 and ½ hours
  ago. Held pressure but could not stop the
  bleeding. Then started spitting out clots,
  gagging on blood, and then had bleeding from left
  nostril. Last ate 3 hours ago.
• PMH Hypertension, TIA, arthritis
• PSH Total knee replacement
• Meds HCTZ, metoprolol, ASA 81mg
• Soc Retired accountant, lives with wife, grown
  children, no smoking, social alcohol

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Physical exam

• Patient is sitting upright on the gurney, and is
  bleeding vigorously from the right nostril
  despite an anterior nasal packing. He is leaning
  over a basin and spitting bright red blood and
  large clots into it. A left foley balloon is in
  place and held against the nostril with a kelly
  clamp.

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Physical exam

• Gen appears anxious, skin is pink, voice sounds
  normal. No petichiae, no echymoses, no scleral
  icterus
• T 37 HR 110 BP 190/90 RR 22 sat 98 room air
• Ears are clear, no effusion or retraction
• Blood seen streaming down oropharynx rightleft
  side
• Neck full ROM no adenopathy
• Chest CTAB Cardiac tachycardic
• Abdomen soft NT, ND

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Labs

• CBC, Chem 7, Coags all normal

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Nasal exam

• External nose is normal
• Right anterior pack removed. Vigorous bleeding
  from right nostril. Afrin applied. Suctioned
  extensively, no evidence of bleeding at
  Kisselbachs plexus. Bleeding is too vigorous to
  identify a specific site.

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Management

• Posterior pack placed on the right. Left
  posterior pack removed, left side suctioned. No
  bleeding site encountered.
• Oropharynx examined no active bleeding
• Admitted to ICU for airway observation

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Management Protocol
Adapted from Marks SC Nasal and sinus surgery
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General approach to the actively bleeding
epistaxis patient

• Evacuate anterior clots
• Decongest and anesthetize the anterior nose
• Using a headlight or preferably a rigid nasal
  endoscope, examine the nasal cavity
  systematically
• Cauterize any bleeders using cautery (requires
  local infiltration of lidocaine), silver nitrate,
  or TCA, or apply anterior packing, or both
• If site not encountered anteriorly, evaluate
  posterior
• Place posterior packing if necessary
• Treat underlying abnormality
• Packs for 1-5 days

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Anterior pack
Modification from this picture- have both packing
ends towards the front
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Posterior Pack
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Posterior pack
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Posterior packs

• Technically is an anterior/posterior pack
• Foley catheter advance along floor of nose until
  into nasopharynx. Fill balloon with 5-10 cc and
  then pull snugly. Then fill with 3-5 cc more.
• Overinflation can cause nasopharyngeal
  obstruction and palate necrosis
• Anterior pack then placed
• Protect the nasal ala with gauze or eye pads
• Removed after mucosa has had time to heal at
  least 48 hours to 5 days

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Complications of packing

• Toxic shock
• Ulcerations
• Nasopulmonary relex

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Surgical/invasive management

• Selective arterial embolization
• Posterior endoscopic cautery
• Internal maxillary artery ligation
• Ethmoid artery ligation

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Internal maxillary ligation
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External ethmoid ligation
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• Lynch incision carried down to orbital
  periosteum.
• Periosteum elevated with freer.
• Lacrimal fossa and frontoethmoid suture
  identified, suture line followed posteriorly
• Anterior ethmoid found 15-20 mm posterior to
  anterior lacrimal crest
• Artery clipped/ligated.

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Coagulation
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Warfarin

• Mechanism blocks the regeneration of vitamin
  K(1) epoxide, thus inhibiting synthesis of
  vitamin K-dependent clotting factors which
  include factors 2, 7, 9 and 10, and the
  anticoagulant proteins C and S
• Half life one week
• Reversal FFP corrects clotting time
  immediately, Vitamin K corrects clotting time
  in 6 hours

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Heparin

• Causes configuration change in antithrombin III,
  increasing the potency
• Onset immediate
• Half life 1.5 hours
• Reversal protamine

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Platelets

• Platelets adhere to vessel wall via von
  Willebrand's binding to glycoprotein Ib.
• Platelets release storage granule including ADP
• Thromboxane A2 synthesized from arachidonic acid
• ADP, thromboxane A2, and other components recruit
  and activate additional platelets from the
  circulation
• Complex with membrane glycoprotein IIb/IIIa.

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Aspirin

• Mechanism - potent inhibitor of both
  prostaglandin synthesis and platelet aggregation
  due to the acetyl group on the aspirin molecule,
  which inactivates cyclooxygenase via acetylation
• Half live 6 hours
• Duration of action permanent, so lasts as long
  as the platelets, about one week
• Reversal Platelets

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Plavix

• Mechanism - inhibits platelet aggregation by
  selectively and irreversibly inhibiting the
  binding of adenosine diphosphate (ADP) to its
  platelet receptor and the subsequent activation
  of ADP-mediated glycoprotein GPIIb/IIIa complex.
  Since this action is irreversible the remainder
  of the platelet lifespan is affected .
• Duration lifespan of platelet, about 1 week
• Reversal platelets
• Half life 8 hours

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