Georgie Harris on Epistaxis: Stopping the bleeding when you can't stop the anticoagulation

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BCC4: Georgie Harris gives an ENT perspective into managing patients with epistaxis in the ICU.

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  • More practical guide to how I try to deal with thingsICU – complex pts, often can distract us from basics…… storyTalk mostly about epistaxis…same principles for oral cavity and bleeding trachesWhat makes the ENT haemorrahge so diferent, why is it so difficult
  • Supply high output blood vesselsInternal carotidExternal carotidAnastamose these vessels as superficially as possible under friable mucosaEncase it in non-compressible boneMake access limited
  • Kesselbach’spleus in Little’s area - Anastomosis between:Sphenopalatine artery (IMAX)Greater palatine artery (IMAX)Anterior ethmoid artery (opth from ICA)Superior labial art of facial arteryWoodruff’s plexus – SPA (IMAX) which gives pharyngeal and post nasal, posterior ethmoidal (oph) and ascending pharyngeal (ECA)
  • Nose – thudicum speculum, nasal speculumOral cavity – tongue depressorLIGHTSuction – frasier or y suctionPacking forceps, or some tool to let you dab or apply pressure.Topical therapies.Plan B - packing
  • Two handsGood light source both critical
  • Get a good viewAnterior bleed most commonInferior turbinate most commonly traumatisedSeptal spurs
  • Silver nitrate –only if pin point area, not so good if anticoagulated, light touch for 2-3 secs then work outward circumferentially light sensitive, avoid skin, one side onlyCan use trichloracetic acid or diathermy
  • Not first line treatmentTopical decongestant, anaestheticSecure pack if neededProphylactic antibioticsBe aware of complications – trauma to mucosa, reduced mucosal transport from respiratory epithelium -sinusitis, toxic shock, dislodgement
  • RapidRhino: hydrocolloid (carboxymethylcellulose)Platelet aggregator, lubricant, clot preserved on remova
  • Packing - Not a first line treatment…not a blind procedureAll packing materials are traumatic to mucosa
  • Georgie Harris on Epistaxis: Stopping the bleeding when you can't stop the anticoagulation

    1. 1. Stopping the bleeding….from the ENT point of view Georgie Harris ENT Registrar
    2. 2. Why is it such a problem? High output vessels Anastomoses under friable mucosa Limited compression from surrounding structures Limited access
    3. 3. High vascularity Kesselbach’s plexus Woodruff’s plexus
    4. 4. Choose your tools….
    5. 5. Get a good view….
    6. 6. Know where to look…..
    7. 7. Identify bleeding point…. Remove clot Decongest/anaesthetise Cophenylcaine forte Drixine/otrivin Most can be controlled with simple measures
    8. 8. Topical measures Direct pressure Cotton ball soaked with cophenylcaine forte Cautery Silver nitrate Adjuvant measures Surgicel Nasalate cream Vaseline Post cautery care important
    9. 9. Packing Nose – Rapid rhino Oral cavity – throat pack with adrenaline Trache site – Surgicel Other options – vasgauze, merecel
    10. 10. Rapid Rhino
    11. 11. If all else fails….. Surgical intervention EUA SPA ligation Maxillary artery ligation Anterior ethmoidal artery ligation Angiography/embolisation
    12. 12. Don’t forget the basics… Choose your instruments Get a good view Know where to look Topical measures first Ask the obvious but often forgotten question
    13. 13. Questions?

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