Code Red: AN ENT EMERGENCY.
Epistaxis, or bleeding from the nostril, nasal cavity or nasopharynx, is common, occurring in up to 60 per cent of the general population. Of these only ten per cent of patients will present for treatment (Villwock & Jones, 2013) because the bleeding cannot be stopped with first aid measures, or is reoccurring too frequently. Epistaxis is divided into two categories; anterior or posterior, depending on the location of the bleed in the nose.
As can be seen in Figure One, the rich vascular supply means that the epistaxis can be very dramatic which can be very distressing for the patient. Bleeding typically occurs when the nasal mucosa erodes and the exposed vessels break. More than 90 per cent of bleeds occur anteriorly and arise from the Little's area, where the Kiesselbach plexus forms on the septum (Villwock & Jones, 2013). Anterior bleeding tends to be an ooze. Located further back in the nasal cavity, posterior bleeds pump. They create a greater risk of airway compromise and aspiration of blood and are difficult to control under local anaesthetic conditions.
Local causes of epistaxis include:
* nose picking;
* facial trauma;
* nasal surgery (acknowledged risk of endoscopic sinus surgery);
* dry weather (low humidity);
* mucosal irritation from topical medicines;
* septal deviations and spurs;
* allergic rhinitis;
* benign and malignant tumours.
Systemic causes include:
* congenital coagulopathies (Haemophilia and Von Wilebrands disease);
* oral anticoagulants;
* Hereditary Haemorrhagic Telangiectasia.
Idiopathic causes account for 10 per cent of epistaxis cases. Even after a thorough history, no identifiable cause can be found.
Epistaxis has a bimodal age distribution with a higher incidence in children under 10 years probably attributed to nose picking and another peak between 45 and 65 years of age. Below the age of 49 years there are more males than females hospitalised with epistaxis after which the distribution equalises. This trend is thought to be attributed to the presence of oestrogen (Kucik & Clenney, 2005).
During the examination, severity, frequency, duration and precipitating factors that led to bleed are determined. A general medical history is obtained, including: medical conditions, current medications and social factors.
The first line of treatment for epistaxis is at home and is aimed at forming a clot in order to stop the bleeding.
* Tilt head slightly forward;
* Pinch nose under bony ridge so alars come together (see Figure 2);
* Hold for at least 10 minutes continuously and uninterrupted;
* An icepack can be placed above the bridge of the nose.
If the bleeding does not stop after an hour to an hour and a half, then a trip to the Emergency Department (ED) is required where the on-call ENT registrar will be notified. The affected nasal passage and area is determined, local anaesthetic administered and a pack, usually a Rapid Rhino nasal pack, will be inserted (See Figure 3).
If the bleeding has stopped, the rapid rhino pack will be deflated for half an hour and then removed. Sometimes the bleeding site requires cauterisation. This may be done chemically with a silver nitrate stick or electrically with bipolar diathermy. The patient will wait for an hour and is then discharged home to rest with a post epistaxis event advice.
Patients with a suspected posterior source of bleeding will be admitted and almost certainly sent straight to the Operating Theatre (OR) to have the offending artery clipped. Usually the Posterior Ethmoid Artery or the Sphenopalatine Artery.
By the time your patient comes to the OR, their nasal passages will be very tender. They will have swallowed a lot of blood, be feeling extremely nauseous and will want to spit out blood clots that have formed in the nasal pharynx. Keep a vomit bowl handy at all times both pre- and post-operatively. Your patient's airway anatomy may be difficult to visualise due to the large amount of blood which may mean they could be difficult to intubate, so keep the suction handy during this time.
Suggestions for Scrub Trolley
* Nasal prep as per Surgeons' preference;
* Head drape;
* 20 ml syringe to let balloon down from Foley catheter or rapid rhino;
* Nose tray/ Endoscopic sinus extras;
* Rigid endoscope and washing system;
* Stamberger bipolar suction;
* Vascular applicator and clips (see Figure 4);
* Post-operative nasal packing;
* Nasal bolster.
Discharge instructions post epistaxis include no heavy lifting, nose blowing or picking, avoid straining to pass stools and minimise very hot drinks and showers.
I also like to warn the patients that they may have black stools, and old blood clots in the nasal passages can take up to two months to remove.
Post-operative Tonsillectomy Bleed
A severe post-operative tonsil bleed is an emergency as it can be lethal. The two types of haemorrhage are primary and secondary. Primary occurs within the first 24 hours. The main risk of bleeding occurs between Day 7 and 10. This is when the eschar falls off and the tonsil bed has not completely healed. Figure 5 shows what the Eschar formation looks like on the tonsil bed. Small surface vessels are exposed to local trauma.
Figure 6 demonstrates the blood supply to the palatine tonsil. As with epistaxis, your patient will have been swallowing a lot of blood so watch for vomiting. The anaesthetic team will require considerable support. Trying to intubate during a severe postoperative haemorrhage is extremely stressful.
Suggestions for scrub trolley
* Tonsillectomy tray;
* Head drape;
* Lots of small swabs. Vigilance at swab count required;
* Electric cautery;
* Suture for tying offending vessel.
Haematoma formation post-Thyroidectomy
An extremely rare complication of thyroidectomy is formation of a postoperative haematoma. The risk to the patient is life threatening due to pressure on their airway. This is where the skill of your PACU and surgical peers come into their own. Eighty per cent of major bleeds occur within the first 6-24 hours. The primary and secondary means of closure must be released immediately if the airway is compromised. The surgeon may have used staples or a non- dissolvable suture as their choice of primary closure. A dissolvable suture will have been used as the secondary closure. The surgical team will then take their patient back to the Operating Theatre to arrest the bleeding and remove the clots.
About the author: June Richardson qualified as a Registered Comprehensive Nurse from Auckland Technical Institute in 1986. Travel and work opportunities saw June accept a role to train as a Perioperative Nurse in Scotland in 1988. On returning to New Zealand, June commenced employment in the main operating theatres at Dunedin Hospital in 2000. Her specialty area became ENT in 2001. A desire for new challenges meant June left to become an ENT Outpatients Clinic nurse in 2012.
Kucik, C.J., Clenney, T. Management of epistaxis. Am Fam Physician 2005; 71:305.
Villwock, J.A., Jones, K. Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngol Head Neck Surg 2013; 139(12):1279-1284. doi:10.1001/jamaoto.2013.5220
by June Richardson Rn, Pg Cert. (Nursing Speciality).
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|Author:||Rn, June Richardson|
|Publication:||The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation|
|Date:||Jun 1, 2018|
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