Epistaxis

193 Epistaxis



Karen H. Calhoun, Minka Schofield


Epistaxis is a nosebleed. It ranges from minor blood-tinged mucus when blowing the nose to life-threatening hemorrhage. The focus in this chapter is on prevention, diagnosis, and management of the types of epistaxis that occur commonly in an intensive care unit (ICU) setting. Almost all epistaxis occurs incidentally in patients hospitalized for other reasons, and a significant proportion of ICU nosebleeds are iatrogenic.



image Anatomy and Physiology



Internal Nasal Anatomy


The interior of the nose is divided in half by the bony cartilaginous septum and its mucoperichondrial covering. The septum thus makes up the medial wall of each nasal vault. The floor of the nose is formed by the palatal bone, sloping slightly downward as it goes back. The nasal cavity roof is made up of the sphenoid bone posteriorly, the cribriform plate (ethmoid bone), and the frontal bone anteriorly. Anteroinferiorly, the nostril opens into the nasal vault. The first 8 to 10 mm of nasal lining, going posteriorly from the nostril, is hair-bearing skin. The rest of the nose is lined with respiratory mucosa. The posterior extent of the nasal vault is the choana, or posterior nasal aperture, opening into the nasopharynx.


The most complex nasal anatomy occurs on the lateral wall of each vault, with three bony protrusions, the turbinates, extending into the nasal vault. The inferior turbinate is the biggest, and the superior one, the smallest. The nasolacrimal duct opens into the nasal cavity under the inferior turbinate. The maxillary, anterior ethmoidal, and frontal sinuses drain into the ethmoidal infundibulum, which opens under the middle turbinate. Posterior ethmoidal sinus cells open into the nose under the superior turbinate, and the sphenoidal sinus opens into the nose above and behind the superior turbinate.



Vascular Anatomy


Internal nasal tissue derives blood supply from both the internal and external carotid systems. The internal carotid artery supplies the anterior and posterior ethmoidal arteries via the ophthalmic artery. The external carotid artery supplies the nose via the internal maxillary artery and the facial artery. The sphenopalatine artery (branch of the internal maxillary), the superior labial artery (branch of the facial artery), and the anterior ethmoidal artery (branch of the ophthalmic artery) together supply Kiesselbach’s plexus in Little’s area of the anteroinferior septal mucosa. This rich vascular supply ensures plentiful bleeding when the mucosa is irritated or breached, resulting in epistaxis.



Nasal Physiology


The nose’s primary function is conditioning inspired air and conducting this air into and out of the pharynx. In a normal nose, air is warmed, humidified, and filtered of particulate matter before reaching the nasopharynx. The nose also contains sensor cells for olfaction in the superior nasal vault and improves vocal resonance.



image Healthcare Personnel Safety


The patient with epistaxis is often scared, snorting or blowing out blood in attempts to clear the nasal or pharyngeal airway. Blood droplets can be widely and forcefully scattered. Any physician or other healthcare worker caring for a patient with epistaxis must observe Universal Precautions. The caregiver should be gowned and gloved and wear eye protection and a facial mask.



image Location of Bleeding


Otolaryngologists refer to nosebleeds as anterior or posterior. This is both an anatomic and a management differentiation.


Most “spontaneous” bleeding in the anterior half of the nose comes from Kiesselbach’s plexus, an area easily seen with a nasal speculum and headlight. This area can be irritated by wiping the nose with a tissue, picking the nose, breathing dry or cold air, or being exposed to environmental factors such as cigarette smoke and other airborne irritants and chemicals. Most spontaneous bleeding in the posterior part of the nose originates from the sphenopalatine artery, often near the posterior end of the inferior turbinate. Iatrogenic bleeding can occur anywhere in the nose where mucosa is traumatized.1



image Diagnosis


The basic diagnosis of epistaxis sounds easy; epistaxis is present when there is blood coming out of the nose. In the ICU setting, however, with the patient supine and often with diminished alertness, blood from a nasal source may drain under the influence of gravity back into the nasopharynx, pooling there and first being noticed as blood from the mouth. Looking in the nose and nasopharynx of patients bleeding from the mouth may lead to rapid identification of a bleeding source. After determining that bleeding is originating in the nose, the next steps in diagnosis are determining exactly where in the nose the bleeding is coming from, how much bleeding there is, and whether it is tapering off or continuing unabated.


Anterior speculum examination with a good headlight and suction usually permits identification of focal anterior bleeding. The exact site of more posterior bleeding, if intermittent or slow, can be determined with a rigid sinonasal endoscope with gentle suction and irrigation. Topical decongestant/anesthetic spray is instilled into the nose before this examination for control of bleeding and patient comfort.


Sometimes, even with the endoscope, a specific source of bleeding cannot be identified. The two most common causes of this are (1) generalized mucosal ooze in a patient with systemic coagulopathy and (2) copious bleeding that obscures visualization despite irrigation and suctioning.



image Treatment



Focal Anterior Bleeding


For spontaneous anterior bleeding from Little’s area, pinching the anterior nose firmly between the thumb and finger provides pressure that often controls the bleeding. Firm pressure is applied for 5 minutes without interruption and then is gently released. If bleeding persists, pressure should be applied for an additional 5 minutes. Pressure can be combined with a topical decongestant such as oxymetazoline or Neo-Synephrine to aid in bleeding cessation via vasoconstriction.


If there is a single identifiable anterior source such as a small laceration or varicosity, cautery with a silver nitrate stick or electrocautery may provide permanent cessation. For cautery, additional topical or injected anesthetic will make the patient more comfortable. This can be done by saturating a small cotton ball or pledget with a decongestant mixed with an anesthetic solution such as 4% lidocaine hydrochloride. The cotton ball or pledget should remain inside the anterior nasal cavity for 5 to 10 minutes. If additional anesthesia is needed, lidocaine with epinephrine (commonly 1% lidocaine in 1 : 200,000 epinephrine) can be injected into the mucosa under direct or endoscopic visualization without causing the patient much discomfort.


If silver nitrate cautery is used, the stick is applied directly to the oozing mucosa, cauterizing only the actively bleeding area. The mucosa touched by silver nitrate becomes black immediately. Once bleeding is well controlled, the mucosal area is gently rinsed with saline solution. If electrocautery is used, the grounding pad (if necessary with the unit) is applied to the patient and the oozing area cauterized. With both techniques, the “dose” of cautery used should be the minimum required to control bleeding, avoiding damage to nearby normal mucosa. A small piece of Gelfoam can be applied to the cauterized area. Antibiotic ointment is applied to the area twice a day for 3 to 5 days. Excessive cauterization should be avoided, since this can lead to inadvertent septal perforation.


A commercially available “pack” can also control anterior bleeding. These packs do not conform as well to the entire shape of the nasal vault in the way packing can and so may be less effective (depending on the exact site of bleeding). They are, however, quicker and easier to place than anterior packing, which is an acquired skill. Nasal tampons such as Merocel (Xomed) are generously coated with surgical lubricant then gently inserted into the nasal cavity dry and compressed. After the tampon is in place, it is expanded with saline to exert pressure on the nasal mucosa.

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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Epistaxis

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