Disclosures No More Bloody Mess: A Practical Guide to � No relevant financial interests in any product discussed today Ending ENT Bleeding H. Gene Hern, MD, MS, FACEP, FAAEM Assoc. Clinical Professor, UCSF Residency Director Alameda County - Highland General Oakland, California Objectives Three Things � Explain the relevant anatomical structures � HIGHLY Anxiety Provoking for patient and in ENT bleeding provider � Best evidence for evaluation and � Protect Yourself treatment � Methodological Approach � Discuss first level and advance techniques to stop ENT bleeding in the ED 1
Why is ENT Bleeding What We Will Cover important?? � Epistaxis � High potential morbidity and mortality � Oropharyngeal Bleeding � Multiple difficult to reach spaces � Trach and Cancer Bleeding � Extension and swelling can involve � Common ENT Hematomas and � Airway Complications � Airway � Airway Case � 48 year old male with URI in Flu Season. Cough, sneezing, presents with epistaxis x 2 hrs. � Coughing up blood � No hx of HTN � What are you thinking first? � What are some common causes of his bleeding? 2
� Case Alternative… � What if he were 5 years old?? Epidemiology Anatomy � How common? � Anterior Bleeds � 60% of Adults have had epistaxis � >90% of all episodes � <10% require medical attention � Many arterial branches form Kiesselbach’s plexus (also called Little’s Area) � Bimodal Distribution � <10 � Between 45 - 65 3
Etiology � Nose Picking � Dry Air � Mucosal Hyperemia (Rhinitis) � Chronic Excoriation (Cocaine use) Associated Conditions Uncertain Associations � Anti-Coagulation � Aspirin � Study of habitual bleeders -> No association � Hereditary Bleeding of ASA use. Beran, JORS, 1986 � Osler-Weber-Rendu � Whereas… � Von Willebrand Dx � Another study found a RR of 2.17-2.75 for � Neoplasm (esp in Asian pts.) ASA use. Tay, AORL, 1998 � Nasal Steroids (4x increase than controls) 4
Uncertain Associations Evaluation � Hypertension?? � Initial Evaluation � Airway Assessment � Some studies suggest correlation � Cardiovascular Stability � Studies designed to test the relationship have been unable to confirm � Vasculopathic effects-> Long term risk � May not cause epistaxis, but makes it harder to control… Evaluation Examination � History � Set up � Anticoagulation � Personal Protection � Recent Trauma � Face Mask � Tumors � Gown � Drug Use � Gloves � Interdigitation � Dental Chair / Upright Bed � Bright Light � Emesis Basis for blood 5
???? Evaluation � Lab Studies? � Generally no � INR if anticoagulated � CBC if massive or prolonged bleeding or if symptomatic (dizzy, lightheaded) 6
Initial Tamponade � Patients may achieve their own � Elbow/knee/palm/chin hemostasis � Instructions � Blow your nose – to remove clots � Spray Oxymetazoline (Afrin) to hasten hemostasis � Pinch Alae tightly against septum for 10-15 minutes Initial Tamponade Examination � Oxymetazoline (Afrin) � Pre Treatment � Anesthetic � Careful with Neo-Sinephrine � Lido � Case reports of intra-operative death � Lido with Epi � Careful with Cocaine � Cocaine??? Careful (case reports of MI) � Further Case reports of MI � Have patient blow nose gently to remove � No Acute BP reduction clots � Not been studied, not recommended 7
Examination Examination � Use a Nasal Speculum � Evaluate Kiesselbach’s plexus � Oriented superior/inferior � >90% of bleeds originate here � Place index finger against alae against � Vestibule, Turbinates, etc. superior blade of speculum � Stabilizes speculum � Often the source can’t be found � Inferior blade moves � Anterior source which has stopped � Less patient discomfort � Posterior Source Anterior vs Posterior Source � Can be difficult to distinguish � Anterior Epistaxis can bleed profusely � High volume � Drips down throat (if patient tilts head) � Posterior Bleeds may stop spontaneously � In difficult cases � Bilateral Anterior Packing � If still bleeding -> posterior source 8
Treatment - Anterior � First Line � Cautery � Silver Nitrate Sticks � Adequate Anesthesia � Roll sticks over bleeding source � (I use a few rolling them together to minimize time) � White precipitate results Treatment - Anterior Treatment - Anterior � Merocel tm Sponge � Next � Nasal Packing � Prior Packing � Proper Patient Position � Ribbon Gauze (stacking layers onto floor of cavity) � Topical Anesthetic � Merocel tm Sponges/Tampon � Trim Insertion Edge � Synthetic Foam Polymer (less S. Aureus) � Nasal Balloon Catheters 9
Treatment - Anterior Treatment - Anterior � Merocel tm Sponge � Nasal Balloon Catheters � Coat sponge with bacitracin � Easier to use � Insert tampon by sliding along floor of nasal � Epistat tm cavity until entire length is in � Storz T-3100 tm � (If it sticks out, it is NOT deep enough) � Rapid Rhino tm � Expand Sponge with NS � 5cm for Anterior � 7.5, 10cm for Posterior Treatment - Anterior Treatment - Anterior � Rapid Rhino tm Technique � Rapid Rhino tm � Balloon catheter � Patient Positioning/Pretreat with anesthetic � Large Low pressure balloon � Soak Catheter in STERILE water (not NS) � Carboxylmethylated Cellulose Mesh � Slide along floor until proximal fabric lies within nares � Self Lubricates when placed in sterile water � CMC mesh fibers act to promote thrombosis 10
Treatment - Anterior Treatment - Anterior � Rapid Rhino tm Technique � Thrombogenic Foams/Gels � Inflate with air. � Promote thrombogenesis � Stop when pilot cuff is round � TXA? – topical application of injectable form � Re eval after 10 min. � Fibrin Glue � Add more air if necessary. � Thrombin Gel/Foam � Each described as useful if cautery fails � Tape cuff to cheek. � Floseal described as effective in posterior bleeds � Cote, JHNS, 2010 � Examples: Surgicel, Gelfoam, Avitene, Floseal, Quixil Treatment - Anterior Treatment - Anterior � Persistent Bleeding � Antibiotics and Toxic Shock Syndrome � May need to pack other side � 16 per 100,000 post operative packings � Provides counter force to packing � Unclear incidence after ED packing � May require ENT consult � No evidence to suggest systemic antibiotics prevent TSS � UTD recs not giving them � 2012 study. 150 patients no infections. � Many ENT specialists still do… � Packing successful 90-95% of time � If no hemostasis – consider posterior source 11
Treatment - Posterior Treatment - Posterior � Balloon Catheters � Balloon Catheter � Similar Insertion principle � Insertion � Often with two balloon system � Similar positioning � Posterior (smaller volume) � Insert until length is within nare � Anterior (larger volume) � Inflate Posterior Balloon � Gently retract until resistance is met (balloon lodges) � Inflate Anterior Balloon Treatment - Posterior Treatment - Posterior � Foley Catheter (fallen out of favor since � Inflate Foley with 5-7ml NS the dual balloon catheters) � Withdraw until it lodges � Similar principle � Gently add a few more ml (3-5ml) � Insert into nare until balloon past posterior � Clamp Catheter in place nasal cavity � Ensure padding between clamp and nare � Again, out of favor. Don’t let clamp touch skin. 12
Treatment - Posterior Treatment - Posterior � Finally: � Further Interventions � Place anterior packing as well � Surgical treatment � Endoscopically � Hospitalization � Ligation � ENT consultation � Angiographic Embolization increasingly � Prolonged packing (> 72 hours) increases common complications � ~ 90% effective � Necrosis � Increase in sig. complications (CVA, blindness) � Infections � ? TSS Epistaxis Summary � Protect Yourself � Use Oxymetazoline � Silver Nitrate/Thrombin foam � Anterior Packing (easy balloon caths) � 24-48 Fu with ENT (no abx) � Posterior Packing gets admitted � +/- Angiographic Embolization 13
Case Oropharyngeal Bleeding � 12 year old female presents with oropharyngeal bleeding � Post Surgical Bleeding � She is 1 day post operative tonsillectomy � Tonsils/Adenoids and went home a few hours ago � Post Dental Extraction � She is not dizzy but her parents are very worried � What is your stepwise approach?? Oropharyngeal Bleeding Oropharyngeal Bleeding � Post Tonsillectomy (most common) � Post Tonsillectomy (most common) � Step Wise Approach � Step Wise Approach � Step 1 � Oxymetazoline drops down the nare on the affected side � Drips down and causes constriction � (Neo-Sinephrine second line) � Gargling the solution may help 14
Oropharyngeal Bleeding Oropharyngeal Bleeding � Post Tonsillectomy (most common) � Post Tonsillectomy (most common) � Step Wise Approach � Step Wise Approach � Step 2 � Step 3 � Epinephrine 1:1000 on 2x2 held in place by � Silver Nitrate patient or clinician � Rapid vaso-constriction so absorption negligible Oropharyngeal Bleeding Case � Post Tonsillectomy (most common) � 39 year old male presents to the ED 4 hours post dental extraction. � Step Wise Approach � He states the bleeding just won’t stop. � Step 4 � He is anxious and frustrated. � Topical Cocaine � Last resort, but effective 15
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