SS-L02-JNA-(A)-Epistaxis

What is epistaxis

Nasal bleeding that affects up to 60% of the population, with peaks in incidence at ages

Which gender is more commonly affected by epistaxis

Males are more commonly affected than females

Where does anterior epistaxis usually originate

Kiesselbach’s plexus in the nasal septum

Where does posterior epistaxis usually originate

Sphenopalatine arteries and Woodruff’s plexus in the posterior nasal cavity

What are common symptoms of posterior epistaxis

Nausea, hematemesis, anemia, hemoptysis, melena, or massive sudden bleeding

What is the primary arterial supply to the nose

Ethmoid branches of the internal carotid and facial & maxillary branches of the external carotid

What systemic conditions are associated with epistaxis

Hemophilia, hypertension, leukemia, liver disease (cirrhosis), platelet dysfunction, thrombocytopenia

Which medications can contribute to epistaxis

Aspirin, anticoagulants, NSAIDs

What environmental factors can contribute to epistaxis

Low humidity and allergens

What is the initial management of epistaxis

Compression of nostrils, nasal plugging with gauze soaked in a topical decongestant, and applying direct pressure for 5-20 minutes

Why should the head be tilted forward during epistaxis management

To prevent blood from pooling in the posterior pharynx, avoiding nausea and airway obstruction

What should be confirmed in a patient with epistaxis

Hemodynamic stability and airway patency

What equipment should be used for examining persistent epistaxis

Headlamp or head mirror, nasal speculum, gloves, surgical mask, and safety glasses

What does diffuse oozing or multiple bleeding sites suggest

A systemic cause such as hypertension, anticoagulation, or coagulopathy

What hematologic tests should be performed in cases of recurrent or unexplained epistaxis

CBC, anticoagulant levels, PT, PTT, platelet count, and possibly blood typing and crossmatching

Which patients with epistaxis may require hospital admission

Elderly patients, those with posterior bleeding, coagulopathy, or complicating conditions like CAD, severe hypertension, or significant anemia

What conditions may warrant close observation after an episode of epistaxis

Coagulopathy, coronary artery disease, severe hypertension, or significant anemia

What vasoconstrictors can be used for anterior epistaxis

4% cocaine solution, oxymetazoline, or phenylephrine solution

What local anesthetics can be used before aggressive treatment of anterior epistaxis

4% cocaine solution, tetracaine, or lidocaine (Xylocaine)

What should be done before treating difficult cases of anterior epistaxis

Obtain intravenous access, especially if anxiolytic medications are needed

How should cotton pledgets be used in anterior epistaxis management

Soak in vasoconstrictor and anesthetic, place in anterior nasal cavity, and apply direct pressure for at least five minutes

What is the next step if vasoconstriction fails to control anterior epistaxis

Chemical cautery with a silver nitrate stick for approximately 30 seconds

What hemostatic agents can be used if chemical cautery fails

Absorbable gelatin foam (Gelfoam) or oxidized cellulose (Surgicel)

When can desmopressin (DDAVP) be considered in anterior epistaxis management

In patients with a known bleeding disorder

When should electrocautery be considered in anterior epistaxis

For larger vessels that do not respond to other treatments

What is a risk of using electrocautery on both sides of the nasal septum

Increased risk of septal perforation

What is the preferred packing method if local treatments fail

Anterior nasal cavity packing with ribbon gauze impregnated with petroleum jelly or antibiotic ointment

How is ribbon gauze packing applied in anterior epistaxis

Insert from posterior to anterior using bayonet forceps and nasal speculum, pressing each layer firmly

What is an alternative to ribbon gauze packing

Preformed nasal tampon (Merocel or Doyle sponge)

How does a nasal tampon work for anterior epistaxis

Expands on contact with blood or liquid; may require vasoconstrictor or saline for full expansion

How long should nasal packing remain in place

Three to five days to ensure clot formation

What are possible complications of nasal packing

Septal hematomas, abscesses, sinusitis, neurogenic syncope, and pressure necrosis

Why is topical antistaphylococcal antibiotic ointment recommended with nasal packing

To reduce the risk of toxic shock syndrome

How common is posterior epistaxis compared to anterior epistaxis

Less common and usually requires otolaryngologist management

How is posterior nasal packing performed

A catheter is passed through the nostril, nasopharynx, and out the mouth, securing a gauze pack in the posterior choana

What is the purpose of posterior nasal packing

To seal the posterior nasal passage and apply pressure to the bleeding site

What are balloon systems used for in posterior epistaxis

To tamponade the bleeding site with a simpler technique than traditional packing

How is a double-balloon device used for posterior epistaxis

The posterior balloon is inflated with 7-10 mL saline, and the anterior balloon is inflated with 15-30 mL saline

What prevents retrograde movement of the posterior balloon in double-balloon devices

Inflating the anterior balloon and placing an umbilical clamp on the catheter near the nostril

How long are balloon packs typically left in place for posterior epistaxis

Two to five days

What is a potential complication of improperly inserted posterior nasal packing

Tissue necrosis due to improper placement or overinflation

What alternative device can be used if a specialized balloon system is unavailable

A Foley catheter (10-14 French) with a 30-mL balloon

How is a Foley catheter used for posterior epistaxis management

Inserted through the bleeding nostril, inflated with 10 mL saline, and withdrawn to seat the balloon in the posterior nasal cavity

What is done after positioning a Foley catheter for posterior epistaxis

The anterior nasal cavity is packed, and traction is maintained with an umbilical clamp beyond the nostrils

What precautions should be taken to prevent soft tissue damage with nasal packing

Padding the umbilical clamp to prevent pressure necrosis

Is oral or intravenous antibiotic therapy necessary for posterior nasal packing

Generally unnecessary, but topical anti-staphylococcal antibiotic ointment may be used

What is the next step if bleeding persists despite packing or balloon procedures

Referral to an otolaryngologist for possible endoscopic localization and cauterization