Epistaxis (nosebleed)

1. Epistaxis(nosebleed)

2. Classification I. According to site • Anterior • Superior; Anterior ethmoid ( bleeding is from above ant. half of middle turbinate) • Inferior; Greater palatine, • Posterior; Sphenopalatine (Bleeding is from below anterior half of middle turbinate II.Primary & secondary

3. Ⅲ.According to Age • Children: • Foreign body, nose picking ,nasal diphtheria. • Adults: • Trauma, idiopathic. • Middle age: • tumors. • Old age: • hypertension.

4. etiological factor of nose bleed 1 local cause: • trauma • inflammation • tumor • deviated nasal septum 2 systom reason

5. AetiologyLocal Causes Trauma • Nose picking, • Fractures (nasal bone, sinuses and/or skull base) • Nasal intubation • Surgery Infections ●Fungal infection ● Suppurative sinusitis ●Influenza, Measles,Diphtheria,Tuberculosis ● Atrophic rhinitis

6. Local Causes • Septum disorder (deviated nasal septum )- spur,perforation. • Foreign body. .

7. Angiofibroma Local Causes • Neoplasms of thenose, nasopharynx and sinuses Hemangioma Carcinom of the Nasopharynx

8. General Causes • Acute infectious disease - Influenza,measles,diphtheria,malaria, typhoid,et al. • Cardiovascular disease -Hypertension, - Atherosclerosis, - Osler-Weber-Rendu disease • Blood clotting problem - Haemophilia, purpura, leukemias, aregenerative anemia,et al.

9. General Causes Osler-Weber-Rendau‘s syndrome

10. General Causes • Vitamin C ,P & K deficiencies. • Severe liver & kidney disease. • Drugs – prescribed - Anticoagulants - Warfarin / Heparin. - Aspirin- platelet function inhibitor. • Toxicosis • Vicarious menstruation -during the period.

11. Environmental reason • High altitudes (drier and lower atm. pressure) • Air-conditioning • Extreme changes in temperature

12. Idiopathic • “Spontaneous” is a better description. • Usually initiated by minor ‘digital’ trauma. • Often associated with atmospheric drying.

13. Anatomy • ICA (branches of ophthalmic) • Anterior ethmoid – supplies lateral wall of nose, nasal • septum, nasal tip • Posterior ethmoid – posterior lateral wall of nose, • superior turbinate and sup septum • ECA (branches of internal maxillary) • sphenopalatine – supplies the posterior septum, • poste-rior middle and superior turbinates • Descending palatine – lower midseptum • Superior labial (facial artery) anterior septum

15. Blood supply of nasal cavity Internal maxillary a. Anterior & posterior ethmoidal a. sphenopalatine a. External carotid Great palatinea.

17. Vessels Involved • Anterior ethmoid a. • Posterior ethmoid a. • Greater palatine a. • Sphenopalatine a. • Superior labial a. Internal carotid External carotid

18. Sites of bleeding • Nasal Septum - Little’s Area 90% of epistaxis from this site. - Rest of septum spurs,perforation ,etc

19. Little’s area Confluence of : • Anterior Ethmoidal a. • Greater Palatine a. • Sphenopalatine a. • Sup. Labial a.

20. Sites of bleeding • Posterior nasal cavity - Woodruff’s plexus - artery often due to hypertension severe

22. Management FIRST AID • Make the patient sit up, pinch or press nose, open mouth and breath. • Ice on forehead.

23. 5 minute pressure Incorrect correct

24. CAUTERIZATION 1) Chemicals • Silver Nitrate stick, • Chromic acid bead. 2) Electrical • Apply ointment and advise against blowing and nose picking.

25. Anterior Pack • For active anterior epistaxis. • Keep for 24-48 hours. • Antibiotics if for more than 24 hrs. SEDATION

26. Anterior pack

27. Anterior Pack

28. PVA foam packs are usually packaged sterile. The foam is compressed to provide smaller packs for easier insertion into tiny areas without pain. The expansion of the compressed foam produces gentle pressure on the mucosa and provides both active and passive absorption.

29. Posterior Pack Posterior packing if bleed is posterior.

30. posterior pack ① ③ ② ④

31. packing

32. OTHER TREATMENTS • Ligation of vessels • Maxillary artery • Ethmoid arteries • External Carotid artery • Embolization-DSA • Blood transfusion • Treatment of primary affection

34. Management protocol