RELEVANT HISTORY TO BE TAKEN • Mode of onset – spontaneous / traumatic • Amount of bleeding • Anterior / Posterior • Which side – right / left • Duration & frequency • Δ? Blood dyscrasia • Δ? Systemic disease FIRST AID Pinch nose between index and thumb for 5 minutes Apply ice pack over dorsum of nose Trotter’s method (obsolete) – let the person bleed till he is hypotensive with a cork between teeth drooping forwards. Breathe through mouth Keep check on pulse, BP and respiration Reassure the patient. HOSPITAL MANAGEMENT Cauterisation under anaesthesia when source is anterior Anterior nasal packing Posterior nasal packing Endoscopic cauterisation SMR in cases of recurrent medial wall epistaxis Ligation of blood vessel External carotid above superior thyroid branch (obsolete) Maxillary artery in pterygopalatine fossa Ethmoidal arteries TESPAL Embolization of vessels Argon / KTP / Nd-YAG laser ablation of vessels in case of Hereditary Haemorrhagic Telangiectasia (Osler Weber Rendu syndrome) ANTERIOR PACKING
Back to front packing Vertical packing
1. Indications: Active anterior epistaxis. Cauterization of the bleeding area is tried first. But if bleeding is profuse and the site of bleeding cannot be localized, anterior nasal packing is done. 2. Method: Nose must be cleared of blood clots by suction and forceps. One meter long ribbon gauze (width 2.5 cm in adults and 12 mm in children), which is soaked in liquid paraffin, is packed tightly in each nasal cavity by layering the gauze from floor to the roof and from before backwards. The initial few centimetres of ribbon gauze are folded upon it and introduced along the floor. If bleeding starts from another nose then posterior nasal bleeding must be suspected. Either one or both nasal cavities may be packed. 3. Removal: Pack can be removed after 24 hours or after 2–3 days. 4. Packing materials: Ribbon gauze Merocel Pope Kennedy nasal sponges Prefashioned anterior nasal balloons Gel foam Oxidized cellulose (Surgicel). 5. Systemic antibiotics are started to prevent infection and toxic shock syndrome. POSTERIOR PACKING 1. Indications: Posterior nasal packing is done when cauterization fails and bleeding site cannot be determined. 2. Methods: a. Gauze: A piece of gauze is rolled into the shape of a cone. Then three silk ties are tied to this cone-shaped gauze. A rubber catheter is passed through the nose. Its pharyngeal end is brought out from the mouth and the silk threads of postnasal pack are tied to it. The catheter along with the silk threads is gradually withdrawn from nose and postnasal pack tied with silk threads is guided into the nasopharynx with the index finger. Anterior nasal cavity is now also packed. The third silk thread, which is cut short, hangs in the oropharynx and helps in easy removal of the postnasal packing. b. Foley’s catheter: The bulb is inflated with saline. The catheter is pulled out and choana is blocked by the inflated bulb. Then anterior nasal packing is done. c. Nasal balloon: The current variety of nasal balloon has two bulbs, one lies in postnasal space while another remains in nasal cavity. TESPAL Stands for Transnasal Endoscopic Spheno Palatine Artery Ligation