Comment prendre en charge une épistaxis sévère en médecine ambulatoire?!
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1 Comment prendre en charge une épistaxis sévère en médecine ambulatoire? Prof. dr. Thibaut. Van Zele Prof. dr. Jean-Baptiste Watelet dienst neus-, keel- en oorheelkunde Universitair Ziekenhuis Gent 2013 Universitair Ziekenhuis Gent
2 Epistaxis: a big problem? 60 % of population experiences 1 episode of epistaxis 12% experiences several times a year epistaxis but only 6% seeks medical help 80% of epistaxis can be treated at the office
3 Stepwise approach: a man/woman with a plan A stepwise approach to epistaxis management is advocated When control is not achieved a timely progression through the management steps is essential 1. initial assessment 2. localize the bleeding site 3. direct therapy 4. tamponnade 5. vascular intervention 3
4 First instruction: (at home) during 15 minutes evt cold pack in neck
5 Strategy in patient with epistaxis Is impressive for both patient and doctor most epistaxis is not life threatening DON T PANIC prepare yourself and the equipment
6 The Dundee protocol The UZ Gent protocol Barnes, Otolaryngol Clin N Am 45 (2012)
7 Step 1: initial assessment prepare yourself: speculum, suction, good headlight, instruments/balloon/ etc let the patient sit on a bed ask the patient to blow the nose gently medical history (cfr risk factors) blood (Hct, Hb, PT/APTT and INR) IV line 7
8 Step 2 localize the bleeding site place cottonoids with pantocaïn and 10 drops 1/1000 epinephrine for minutes mild epistaxis: spray with xylometazoline control 65% of epistaxis cases in GP 8
9 Step 2 localize the bleeding site Look for origin/source of bleeding anterior rhinoscopy nasal endoscopy (can identify in up to 80 % of patients the bleeding site) throat examination Kiesselbach Area of attachment middle turbinate Middle meatus / skull base
10 control bleeding: 2 options 10
11 Step 3: Direct therapy Electrocautery / diathermy Silver nitrate not effective in case of profuse bleeding start around bleeding site and then work towards bleeding site use only one side of nasal cavity treat other side if mucosa is healed completely if necessary cover with procoagulant dressing (surgicell) 11
12 Step 4: Nasal packing or dressings Which one to choose? 12
13 Nasal packings After local anesthesia insert parallel to floor of nose and parellel to nasal septum unilateral unless you observe a shift of nasal septum humidify with saline leave in place for h
14 Nasal packings: balloon tamponnade with Foley catheter 14
15 Nasal packing: Bellocq tamponnade
16 Nasal packing: commercial balloon packs Epistat Rapid Rhino
17 Nasal packing risks CO2 retention with hypoxia always hospitalize patient Balloon packing: painful Necrosis of ala, columella, septum otitis media with effusion Septal luxation (contralateral tamponnade remains controversial) Scarring.
18 Bleeding stopped with tamponnade Leave tamponnade in place preferably 48h Toxic shock? 16,5 in tamponnated patients with have a TSS no data that antibiotics decrease risk >48u amoxi-clav or from first hour in high risk cases Remove packing under controlled circumstances deflate balloon, but leave in nasal cavity for several hours, than remove completely foresee vascular intervention vagal reactions
19 Step 5 Vascular intervention 19
20 Step 5 Vascular intervention % Sphenopalatine artery treated by endoscopic ligation cauterization procedure under general anesthesia not a single artery av 2-3 branches Simmen 2006 Am J Rhinol Voegels R Laryngoscope 2007
21 Endoscopic sphenopalatine cauterisation 21
22 Step 5 Vascular intervention Is more cost effective than balloon tamponnade and long hospitalization High succes rate up to 80% Douglas, Wormald Current Opinion in Otolaryngology & Head and Neck Surgery
23 Step 5: vascular intervention Anterior ethmoidal artery dehiscence up to 40% average 3,5mm below skull base Posterior ethmoidal artery more bony protection at skull base bipolar preferable at skull base with monopolar risk of CSF leak external approach with a Lynch- Howarth incision: clip or cautery of the artery as it traverses the space between the periorbita and lamina papyracea. 23
24 24
25 Step 5: vascular intervention Embolization: UZ Gent only if arterial ligation fails only branches of External carotid artery complications 6-47% CVA arterial dissection necrosis facial skin huid hypoesthesia face 25
26 Remind these special cases of epistaxis epistaxis after fracture of facial bones reduction of fractures be careful with tamponnade: fracture of skull base is possible, masking of a CSF leak severe epistaxis with fracture skull base/ sphenoid sinus bleeding fron sinus cavernosus/internal carotid, fistel angiography
27 Remind these special cases of epistaxis epistaxis after nose fracture branch ethmoidalis anterior anterior tamponnade is sufficient Rendu-Osler-Weber (hereditair hemorrhagische teleangiectasieën) juvenile angiofibroma male adolescents nasal obstruction and severe bleeding on same side sometimes tumor visible on oropharynx 27
28 Conclusion High risk patient that presents with severe epistaxis male of 64 years multiple comorbidities anti-coagulant therapy recent change (<2 weeks) in anti-coagulant therapy between 2AM and 8AM Treated with packing and in 46,5% with vascular intervention Success rate 82,9% 5 years survival 75,9% IMPORTANCE OF MULTIDISCIPLINARY COLLABORATION 28
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