Here is a little information on Epistaxis...

1. BY : Dr. ANUGRAHA RAJAN

2.  BLEEDING FROM INSIDE NOSE
 PRESENTS AS A EMERGENCY
 IT IS A SIGN, NOT DISEASE

3.  NASAL SEPTUM :
 INTERNAL CAROTID SYSTEM
 EXTERNAL CAROTID SYSTEM

5.  LATERAL WALL
 INTERNAL CAROTID SYSTEM
 EXTERNAL CAROTID SYSTEM

6.  ANTERIOR INFERIOR PART OF SEPTUM,
ABOVE VESTIBULE
 4 ARTERIES : ANTERIOR ETHMOIDAL, SEPTAL
BRANCH OF SUPERIOR LABIAL, SEPTAL
BRANCH OF SPHENOPALATINE AND
GREATER PALATINE ANASTOMOSE –
KIESSELBACH’S PLEXUS
 COMMON SITE FOR EPISTAXIS IN CHILDREN,
ADULTS

7.  WOODRUFF’S PLEXUS : PLEXUS OF VEINS
INFERIOR TO POSTERIOR END OF
INFERIOR TURBINATE
 SITE OF POSTERIOR EPISTAXIS IN ADULTS

8.  LOCAL CAUSES :
 TRAUMA : FINGER NAIL TRAUMA, NOSE
INJURY, INTRANASAL SURGERY
 INFECTIONS :
ACUTE : VIRAL RHINITIS, ACUTE SINUSITIS
CHRONIC : ATROPHIC RHINITIS,RHINITIS
SICCA, TB

9.  FOREIGN BODIES : NON-LIVING(
RHINOLITH), LIVING (MAGGOTS, LEECHES)
 NEOPLASM OF NOSE , PNS: HEMANGIOMA
, PAPILLOMA, CARCINOMA
 ATMOSPHERIC CHANGES : HIGH
ALTITUDE, SUDDEN DECOMPRESSION
 DNS
 NASOPHARYNX : ADENOIDITIS, JUVENILE
ANGIOFIBROMA ,MALIGNANT TUMOURS

10. GENERAL CAUSES :
 CVS :HYPERTENSION , MITRAL STENOSIS
 BLOOD DISORDERS : HAEMOPHILIA,
VITAMIN K DEFICIENCY, APLASTIC
ANEMIA
 LIVER DISEASE : CIRRHOSIS
 KIDNEY DISEASE : CHRONIC NEPHRITIS
 DRUGS : SALICYLATES, ANTICOAGULANTS

11.  MEDIASTINAL COMPRESSION BY
TUMOURS
 INFECTION : INFLUENZA, MEASLES,
DENGUE
 VICARIOUS MENSTRUATION
IDIOPATHIC CAUSES

12.  LITTLE’S AREA : 90% CASES
 ABOVE MIDDLE TURBINATE : FROM ANTERIOR &
POSTERIOR ETHMOIDAL VESSELS
 BELOW MIDDLE TURBINATE:SPHENOPALATINE
ARTERY
 POSTERIOR PART OF NASAL CAVITY
 DIFFUSE : SEPTUM & LATERAL WALL
( SYSTEMIC / BLOOD DISORDERS)
 NASOPHARYNX

13.  ANTERIOR : BLOOD FLOWS OUT FROM
FRONT OF NOSE
 POSTERIOR EPISTAXIS : BLOOD FLOWS
BACK TO THROAT

14. ANTERIOR
 MORE COMMON
 OCCURS AT LITTLE’S
AREA
 OCCURS IN CHILDREN,
YOUNG ADULTS
 CAUSE : TRAUMA
 BLEEDING – MILD,
LOCAL PRESSURE
/ANTERIOR PACK
POSTERIOR
 LESS COMMON
 OCCURS AT
POSTEROSUPERIOR
PART OF NASAL
CAVITY
 OCCURS AFTER 40
YEARS
 CAUSE : HTN,
ARTERIOSCELOROSIS
 BLEEDING : SEVERE ,
HOSPITALIZATION,
POST NASAL PACK

15.  FIRST AID : PINCH NOSE WITH THUMB & INDEX
FINGER FOR 5 MINUTES
GENERAL MEASURES :
 REASSURE PATIENT
 CHECK PULSE, BP, RESPIRATION
 MAINTAIN HAEMODYNAMICS
 ANTIBIOTICS TO PREVENT SINUSITIS IF PACK KEPT
> 24 HOURS
 INTERMITTENT OXYGEN IN BILATERAL PACKS (
NASOPULMONARY REFLEX CAUSES INCREASED
PULMONARY RESISTANCE )

16.  TROTTER’S METHOD : PATIENT SITS,LEANS
FORWARD OVER BASIN TO SPIT BLOOD
AND BREATHE QUIETLY FROM MOUTH
 COLD COMPRESS TO NOSE : REFLEX
VASOCONSTRICTION
 CAUTERIZATION : FOR ANTERIOR
EPISTAXIS, DONE WITH SILVER NITRATE

17.  NOSE CLEARED OF NOSE CLOTS BY SUCTION, IF
SITE NOT LOCALISED / PROFUSE BLEEDING
 USE RIBBON GAUZE SOAKED WITH LIQUID
PARAFFIN
 FIRST INSERT ALONG FLOOR, THEN PACK
WHOLE NASAL CAVITY FROM FLOOR TO ROOF &
FROM BEFORE BACKWARDS
 REMOVED AFTER 24 HOURS / 2-3 DAYS
 SYSTEMIC ANTIBIOTICS PREVENT SINUSITIS,
TOXIC SHOCK SYNDROME

19.  DONE IN POSTERIOR BLEEDING INTO THROAT
 TIE 3 SILK TIES TO CONE SHAPED GAUZE
 RUBBER CATHETER PASSED THROUGH NOSE,
BROUGHT OUT FROM MOUTH
 END OF SILK THREADS TIED TO IT , CATHETER
WITHDRAWN
 PACK MOVED INTO NASOPHARYNX WITH
INDEX FINGER
 ANTERIOR NASAL CAVITY PACKED , SILK
THREADS TIED OVER DENTAL ROLL
 THIRD SILK HANGS IN OROPHARYNX ( FOR EASY
REMOVAL OF PACK)

21.  FOLEY’S CATHETER ( 12-14 F)
 AFTER INSERTING, BALLOON INFLATED WITH
5-10 ML SALINE
 BULB INFLATED WITH SALINE, PULLED
FORWARD TO BLOCK CHOANA
 ANTERIOR NASAL PACK KEPT
 NASAL BALLOON : 2 BULBS- FOR POST NASAL
SPACE & NASAL CAVITY

23.  TOPICAL/GENERAL ANAESTHESIA
 BLEEDING POINT LOCALISED WITH RIGID
ENDOSCOPE
 CAUTERIZE
 LIMITATION : IN PROFUSE BLEEDING,
BLEEDING POINT MAY NOT BE LOCALISED

24.  ELEVATION OF MUCOPERICHONDRIAL FLAP
& SUBMUCOUS RESECTION (SMR)OPERATION
: CAUSES FIBROSIS & CONSTRICTS BLOOD
VESSELS
 LIGATION OF VESSELS :-
 EXTERNAL CAROTID : DONE ABOVE ORIGIN
SUPERIOR THYROID ARTERY
 MAXILLARY ARTERY : DONE IN
UNCONTROLLED POSTERIOR EPISTAXIS
 ETHMOIDAL ARTERIES

25.  TOPICAL / GENERAL ANAESTHESIA
 MUCOSAL FLAP LIFTED FROM LATERAL
NASAL WALL
 SPA LOCALIZED , CLOSED WITH
VASCULAR CLIP
 FLAP REPOSITED
 HIGH SUCCESS IN CONTROL OF
REFRACTORY POSTERIOR BLEED

26.  EMBOLIZATION : THROUGH FEMORAL
ARTERY CATHETERIZATION
 INTERNAL MAXILLARY ARTERY
LOCALIZED , EMBOLIZATION PERFORMED
WITH ABSORBABLE
GELFOAM/POLYVINYL ALCOHOL
 RISKS : CEREBRAL THROMBOEMBOLISM,
HAEMATOMA AT LOCAL SITE

27. THANK YOU