​Kembara Xtra - Medicine - Epistaxis

​Kembara Xtra - Medicine - Epistaxis 
Intractable or refractory epistaxis: recurrent or persistent despite proper packing or several episodes during a short period, each requiring medical treatment Synonym(s): nosebleed Introduction Hemorrhage from the nose including either the anterior or posterior mucosal surfaces Intractable or refractory epistaxis: recurrent or persistent despite appropriate packing Introduction Hemorrhage from the nose involving either the anterior or posterior mucosal

Epidemiology 

Incidence It is very frequent in the United States. Lifetime prevalence is probably less than sixty percent.

Bimodal, with peaks in children up to 15 years old and in adults over 50 years old, notably ages 70 to 79 years old Most prevalent in males 49 years old Rare in children age 2 years old Less than 6% of patients require medical or surgical intervention; accounts for less than one in 200 visits to the emergency room 

Causes and effects: etiology and pathophysiology 

 The distinction between local and systemic sickness. Most nosebleeds are due to local causes.

Anterior: ninety to ninety-five percent of all cases (Kiesselbach plexus).
Posterior: 5–10% of instances (Woodruff plexus); generally branches of sphenopalatine arteries: can be asymptomatic or can present with other symptoms (hematemesis, hemoptysis) Anterior: 90–95% of cases (sphenopalatine arteries): can be asymptomatic or can present with other symptoms (hematemesis, hemopty
Idiopathic: referring to inflammation, irritation, or an injury that occurs locally - Infection (viral upper respiratory infection, sinusitis, tuberculosis, or syphilis)
- Inhalation of irritants (smoking, rhinitis, present or previous cocaine use) – The application of topical steroids or antihistamines – The consistent and excessive use of nasal vasoconstrictor medications
- Septal deviation (disproportionate, unilateral air movement)
- The use of nasal oxygen, low humidity, and CPAP
- Tumors: benign, malignant
– Vascular malformations, particularly in the setting of previous trauma (for example, aneurysm of the carotid artery) Trauma – Epistaxis digitorum (also known as picking one's nose)
— Foreign bodies
– A perforation of the septum – A fracture of the nose – Nasal surgery – Barotrauma

Thrombocytopenia, congenital or acquired coagulopathies, liver or renal illness, chronic alcohol misuse, and leukemia are all systemic conditions.
– Anticoagulant medication use – CHF
Collagen abnormalities; hereditary hemorrhagic telangiectasia (HHT); mitral valve stenosis; multiple myeloma; polycythemia vera; HIV;

Risk Factors Local irritation from multiple causes Anemia and thrombocytopenia are risk factors for recurrent epistaxis Risk factors for recurrent epistaxis include prior septoplasty or turbinectomy procedures, anemia, and other anticoagulants.


Prevention includes using a humidifier at night, keeping fingernails trimmed, and picking at them as little as possible.

Those who take medications that are sprayed in the nose should aim the spray laterally, away from the septum. Spray into the opposite nostril using the hand you normally use (i.e., use your left hand to spray into your right nostril).
Petroleum jelly for the treatment and prevention of anterior mucosal dryness 
Ensure that your hypertension (HTN) is under control, as there is some debate on whether or not it is associated with an increased risk of recurrent epistaxis.


Conditions That Often Occur Together 

 Neoplasm (rare; consider if chronic and unilateral) Hereditary hemorrhagic telangiectasia (HHT) Vascular malformation and telangiectasia
Systemic Thrombocytopenia Coagulopathy (either primary or iatrogenic) Cirrhosis Renal failure
— Alcoholic Drinking

 There is no evidence to suggest a relationship with HTN, however it may make it more difficult to control bleeding. 

Providing an Account of History 

It is important to get checked for signs of anemia and cardiovascular impairment.
Find out which side the bleeding started on, as well as its severity and how long it has been going on for.
Define the terms "trauma" (which can include "nose picking") and "other possible precipitants" (such as using cocaine).
Inquire about any previous bouts of epistaxis, as well as the frequency of those bouts (if applicable).
Determine whether there are any coexisting diseases, such as cardiovascular compromise signs, cirrhosis, or primary coagulopathies.
It is important to review all of your current drugs, such as nasal sprays, anticoagulants, antiplatelets, and treatments that you have already tried.
It is important to check for nausea, hematemesis, and hemoptysis, as these symptoms may point to a more serious and posterior bleeding.

Clinical Examination 
It is important to check that the airway is clear, as well as the cardiovascular system.
Pay close attention to determining if the bleeding is coming from the front or the back of the nasal cavity. The majority of instances are caused by bleeding in the anterior nasal septum.
Ensure that the patient is seated in an upright or semiupright position before performing a formal examination of the nasal cavity. If a nasal speculum is available, use it in conjunction with a dependable light source to enhance visualization of the nasal chambers.
In order to prevent blood from flowing into the posterior pharynx during the intervals between examinations, instruct the patient to bend forward and squeeze their nose (or use nasal clips).

Differential Diagnosis The diagnosis is typically straightforward, but determining the origin of the condition is essential.

If there is any persistent blood loss, it is imperative that posterior bleeding be factored into the differential diagnosis.


Results From the Laboratory 

In the vast majority of straightforward cases, where bleeding can be quickly controlled, laboratory testing is not necessary.

Initial Tests (laboratory and imaging): Mild cases that are sensitive to pressure do not require laboratory testing.
CBC, PT/PTT, and BMP testing for recurring or intractable instances; PT/PTT testing if the patient is on warfarin or any other drug that affects coagulation; cross-matching as necessary.

A toxicology check should be performed whenever there is a reason to suspect that an illegal drug was inhaled through the nose. Imaging should not be performed in the majority of cases.


Additional Assessments, as well as Other Important Factors
If you have recurring unilateral epistaxis, especially if it does not respond to treatment, you should think about a tumor.
Endoscopy of the nose for diagnostic purposes and other procedures
Considerations Relating to Children
Geriatric Considerations are more likely to have anterior, idiopathic, and recurring causes.
More likely to be bleeding from the posterior

Treatment The vast majority of patients are treated as outpatients.

 Home use of Nosebleed QR: a powder consisting of hydrophilic polymer with potassium salt that is available without a prescription and causes scab development 
Patient applies direct pressure by squeezing the lower part of the nose (nasal ala) for five to twenty minutes straight with no breaks in between. In most people, this results in an end to the bleeding.

Blowing your nose is an effective way to remove blood clots from the nasal canal. Placing an ice pack over the dorsum of the nose may also be helpful in achieving hemostasis.

Examine the nasal septum to locate the source of the bleeding.


Prevention 
Attempts at resuscitation, when required. Consider using the "airway/breathing/circulation (ABC)" technique instead.

The First Line Of Defense Is Medication

In the event that general remedies are ineffective, a topical vasoconstrictor might be sprayed into the afflicted naris, such as: 
● Oxymetazoline: 0.05%

● Epinephrine: 1:1,000
● Phenylephrine: 0.5–1%
4% Cocaine in the Second Line of Distribution

Chemical (silver nitrate) or electrical cautery Nasal packing with ribbon gauze, nasal tampons, or a nasal balloon catheter For intractable or refractory cases, consider surgical ligation, endoscopic ligation/cautery, or endovascular embolization.


Referral 

A visit with an otolaryngologist is typically necessary in the event of posterior hemorrhage.
Bleeding in the anterior region that does not respond to conservative treatment, packing, or cauterization 
● Recurrent episodes

Patients diagnosed with HHT are encouraged to begin therapy with an ENT.
Concurrent anticoagulation – If bleeding ceases with packing, you may continue the same dose of warfarin if the international normalized ratio (INR) is therapeutic; however, you should lower the dose if the INR is over therapeutic. – If bleeding continues despite the use of packing, halt the anticoagulation treatment and provide vitamin K 10 mg IV x 1. After 30 minutes, recheck the INR; if it is still greater than 1.5, give PCC.
– Warfarin may be related with higher rates of epistaxis, whereas novel anticoagulation may be associated with reduced rates. When epistaxis strikes, it could be more difficult to maintain control.

Further Methods of Treatment 
Nasal packing can be done with prefabricated nasal tampons or ribbon gauze. It is not required to administer systemic prophylactic antibiotics to the vast majority of patients who use nasal packs. Instead, patients can use topical antibiotics, which may be just as effective but cost less.

 FloSeal is a biodegradable hemostatic sealant that is a thrombin-type gel. In one trial, it was found to be more effective than packing while also being better tolerated.

When compared to anterior packing, a local application of tranexamic acid may shorten the amount of time it takes for bleeding to stop.

 If it is determined that an actively bleeding anterior septal site is present, the ultimate therapy for this condition consists of using gentle silver nitrate cautery for approximately ten seconds. The recommended concentration of silver nitrate is 75%. Use a spiral motion to apply it, beginning around the bleeding vessel and working your way inward.

If you want to lower your chance of perforation, you should restrict cautery, also known as silver nitrate, to just one side of the septum or wait between 4 and 6 weeks between treatments.
Posterior: Posterior packing or tamponade with balloon devices (Foley catheters have been utilized in some cases). Anterior: Anterior packing or tamponade. In most situations, these conditions call for the patient to be monitored in an inpatient setting.
In children with recurrent epistaxis, a Cochrane review found no significant difference in the efficacy of treating the condition with antiseptic nasal cream, petroleum jelly, silver nitrate cautery, or doing nothing at all. – It is possible that the use of silver nitrate cautery followed by four weeks of antiseptic cream is superior than the use of antiseptic cream by itself.


Packing, which consists of layering of Vaseline ribbon gauze (1/2 inch), is one of the surgical procedures.
When using gauze for packing, it is important to ensure that both ends of the ribbon gauze are visible outside of the nostril.
Starting at the bottom and working our way up, we pack in layers.
 Packing should be secured using gauze that is wrapped around the outside of the nostril. – A nasal tampon can be used, but the tip should be lubricated with KY Jelly or an antibiotic cream or ointment before usage. – If the bleeding has slowed, you may need to add more saline to the tampon in order to make it larger. – Merocel and Rapid Rhino packs are often well tolerated and easier to use than gauze packing. Merocel packs are also easier to utilize.

Posterior bleed - In the event that this occurs during an emergency, it is possible to attempt to stop the bleeding by using a posterior packing balloon or a Foley catheter. In both of these procedures, the tube is sent via the nasal passages into the stomach in the same way that a nasogastric tube would be. As soon as it reaches the posterior oral pharynx, the balloon is inflated, and the tubing is pulled back outward to tamponade the posterior bleeding source. If a Foley catheter (10 to 14F catheter) is being used, the balloon can be inflated with 10 mL of saline. Traction is maintained with an umbilical cord clamp, and adequate padding is placed between the clip and the nose to prevent injury.

Admission Hospitalization should be considered for patients who are elderly or who have posterior bleeding or coagulopathy; severe comorbidities are another factor that should be taken into consideration. Admission criteria/initial stabilization Posterior bleed Hemodynamic abnormalities in the patient
Clotting dysfunction: a universal approach using the ABC method. Put an end to the bleeding.


Continued Patient Observation and Monitoring
Monitoring of hemodynamics in the event of a major loss of blood. A minimum of twenty-four hours must pass before the packing can be removed; other people prefer three to five days. The average time between bleeding episodes is between 24 and 48 hours. Packing for longer periods of time is associated with an increased risk of mucosal injury as well as toxic shock syndrome.

Pinching pressure should be applied in the correct manner, and the avoidance of trauma and irritants should be emphasized.
The management of systemic sickness as well as the appropriate use of medication 

Prognosis 

The majority of cases resolve on their own. Beneficial outcomes with appropriate treatment. 

Complications 

Septal perforation Pressure-induced tissue necrosis of the nasal mucosa Toxic shock syndrome with packing Arrhythmias generated by packing (especially posterior) Septal perforation Pressure-induced tissue necrosis of the nasal mucosa

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