How to be effective to save the life of the a patient in a case of intractable epistaxis, avoiding any medicoleagal issue .

1. Saied Alhabash
Skull Base Surgeon,Endoscopist
Canadian Speciality Hospital

5.  Most Epistaxis can stop spontaneously or by
cauterizaion or packing

6.  Refractory or intractable epistaxis is defined as
recurrent or persistent bleeding after
appropriate conservative treatment, or multiple
episodes of epistaxis over a short period of
time, each requiring medical attention 1
 The patient underwent many trials with no
improvement(continuous or recurrent)and
there is HB reduction or very massive bleeding
( no time to wait the result)

7.  artery with name(Dr.Simmen) Or
 Small vessels continue bleeding

8.  If you are in private hospital with no ENT
resident or the ENT does not have the ability to
do SPA ligation(for example)
 If you are dealing with CCU you are dealing
with bleeding disorders
 When you deal with nagging patient or his
relative is lawyer dealing with medical
problems !!!

9.  Quickly
 Safely(for you and for the patient)
 With Efficacy
 Define your choices (admit or refer)
(admit temporary or not)
(SPA ligation vs embolization)

10.  Discuss with your ENT head (if the case is
critical or may be with the medical director)
 Discuss with the cardiologist in details when
the case is related to bleeding disorder
 To Document every step even very small ,and
put imagine you study this case for
medicolegal opinion

11.  30 year old female admitted in CCU with artificial valve thrombosis
 She was on warfarin with previous history of unstable INR( reach 8
when she was admitted in the first time)
 She started bleeding from left
 Anterior packing with cauterization was done with negotiation(with
cardiologist) to stop the warfarin(or at least decrease it), but the
cardiologist resisted that because of the thrombus (which is critical
case in his viewpoint)
 She started bleeding from the other side
 Another anterior packing and cauterization done
 Many times we were called to make some packing
 Many times we negotiated with cardiologist
 Because of severe bleeding we took the permission to do SPA ,it
stopped (hb 7.5)
 Again started bleeding after 5 days from the other side , Spa of the
other side with giving plasma ( informed consent very strict),

14.  Include more than one doctor in these critical
cases and try to take agreement for any
decision
 Include medical director in these cases and
report every single detail
 Explain everything to the patient and give him
the other options
 DO not waste long time with conservative
management specially after surgery

15.  IV pain medication and antiemetics may be
helpful
 Use topical anesthetic and vasoconstrictive
spray for improved visualization and
patient comfort
 Balloon-type episaxis devices often easiest
 Foley catheter or other traditional posterior
packs may be necessary

16. Standard Merocel Merocel with AirwayMeroPack Bioresorbable
Nu Gauze Packing Strips Floseal Hemostatic MeroGel injectable

18.  Always test before
placing in patient
 Fill “balloons” with
water, not air
 Orient in direction shown
 Fill posterior balloon first,
then anterior
 Document volumes used
to fill balloons

20. Bivona Epistaxis Catheter Foley Catheter
Epistat Nasal Catheter Rapid Rhino Nasal Tampon
DR1419

21.  Continued bleeding despite nasal packing
 Pt requires transfusion/admit hct of <38%
(barlow)
 Nasal anomaly precluding packing
 Patient refusal/intolerance of packing
 Posterior bleed vs. failed medical mgmt after
>72hrs (wang vs. schaitkin)

22.  1. patients are admitted for 24 hours of
observation POST LIGATION.
 2. major episode of rebleeding requires nasal
packing and embolization after ligation.
 3. Post-ligation minor episode of rebleeding can be
treated with temporary anterior packing.
 4. Post-ligation transient postoperative
complications (ie, sinusitis or crusting) require an
in-office debridement and 14 days of broad
spectrum antibiotics.
4

23.  Postembolization patients are admitted and
have their nasal packing removed 12 hours
after the procedure.
 2. Following pack removal, patients are
observed for 24 hours in hospital.
 3. Postembolization rebleeding requires nasal
packing and SPA ligation.

27. Date of download: 12/6/2015 .
From: Cost-effectiveness Analysis of Endoscopic Sphenopalatine Artery Ligation vs Arterial Embolization for
Intractable Epistaxis
JAMA Otolaryngol Head Neck Surg. 2014;140(9):802-808. doi:10.1001/jamaoto.2014.1450
Decision Tree Model of TESPAL vs EmbolizationSee Table 1 for a description of the variables used. Postop indicates postoperative;
rebleed indicates episode of rebleeding; SPA, sphenopalatine artery; TESPAL, transnasal endoscopic sphenopalatine artery ligation.
Figure Legend:

28.  Leung et al (2015) found that treatment algorithms of
packing or transnasal endoscopic SPA ligation prior
to embolization has the lowest patient risk, they
recommend SPA ligationposterior packing 
embolization 3
 Rudmik and Leung (2014) found that SPA ligation in
experienced hands is a more cost-effective strategy
compared to embolization for intractable epistaxis 4

29. * Intractable epistaxis is a common
otolaryngology emergency, and the decision to
choose either SPAL or embolization can be
challenging.
* SPAL is the more cost-effective treatment
strategy for patients with intractable epistaxis.
* Future studies are needed to elucidate which
patient cohorts would be best treated with
arterial embolization compared with SPAL

30.  1.Chandler JR, Serrins AJ. Transantral ligation of the internal maxillary artery for
epistaxis. Laryngoscope 1965; 75: 1151-1160
 2.Cost-effectiveness Analysis of Endoscopic SphenopalatineArtery Ligation vs
Arterial Embolizationfor Intractable Epistaxis-Luke Rudmik, MD, MSc; Randy
Leung, MD
 3.JAMA Otolaryngology–Head & Neck Surgery
Published online August 14, 2014

31. Thanks for listening