Question

How to assess an adult patient of epistaxis and outline control of nasal bleed? [4+4]

Hint:

For persistent or recurrent epistaxis, especially in patients with underlying health conditions (e.g., hypertension, bleeding disorders), a thorough work-up and more aggressive treatment approaches may be necessary.

Answer 1

Step 1: Assessment of an Adult Patient with Epistaxis.
The assessment of an adult patient with epistaxis involves obtaining a thorough history, performing a physical examination, and determining the cause and severity of the bleeding. The following steps should be taken:
(1) History:
- Duration and Frequency: Determine how long the bleeding has lasted and if the patient has had previous episodes.
- Onset and Triggers: Ask about recent trauma, infections, or medication use (e.g., anticoagulants, nasal sprays).
- Medical History: Inquire about underlying medical conditions such as hypertension, liver disease, bleeding disorders, or vasculitis.
- Family History: A family history of bleeding disorders (e.g., von Willebrand disease) may be relevant.
(2) Physical Examination:
- Inspection of the Nasal Cavity: Use a nasal speculum to inspect for obvious sources of bleeding (e.g., bleeding from the anterior septum, foreign bodies, or tumors).
- Systemic Examination: Check for signs of systemic causes, including hypertension, liver disease, and clotting disorders.
- Vital Signs: Assess for signs of shock or hypotension in cases of significant blood loss.
(3) Laboratory Tests (if indicate:
- Complete Blood Count (CB: To check for anemia.
- Coagulation Profile: To rule out bleeding disorders.
- Platelet Function Tests: If there is suspicion of a platelet disorder.
Step 2: Control of Nasal Bleed.
The management of epistaxis involves controlling the bleeding, addressing the underlying cause, and preventing recurrence. The following steps outline the control measures:
(1) Initial Measures (For all patients):
- Positioning: Sit the patient upright with the head tilted forward to prevent blood from flowing down the back of the throat and causing aspiration.
- Pinching the Nostrils: Have the patient pinch their nostrils together for 10-15 minutes while breathing through their mouth to apply pressure on the bleeding site.
- Cold Compresses: Apply a cold compress or ice pack to the back of the neck or nose to constrict blood vessels and reduce bleeding.
(2) Topical Treatment:
- Cauterization: If the source of bleeding is visible (e.g., a bleeding vessel in the anterior septum), chemical cauterization using silver nitrate or electrocautery can be used to seal the vessel.
- Topical Vasoconstrictors: Adrenaline (epinephrine) or oxymetazoline nasal spray can be used to constrict the blood vessels and reduce bleeding.
(3) Anterior Nasal Packing:
- Nasal Packing: If the bleeding persists despite initial measures, anterior nasal packing with gauze or inflatable nasal tampons can be placed to exert pressure on the bleeding site.
- Antibiotics: In cases of nasal packing, antibiotics may be prescribed to prevent infections.
(4) Posterior Packing:
- Posterior Bleeding: If the source of bleeding is in the posterior nasal cavity, posterior packing may be required. This involves packing the back of the nasal cavity and may require the use of a Foley catheter or specially designed posterior nasal packs.
(5) Surgical Intervention:
- Surgical Cauterization or Ligature: In refractory cases or when there is a large, persistent bleed, surgical cauterization or ligation of the bleeding vessels (e.g., external carotid artery ligation) may be needed.
- Embolization: In cases of severe, life-threatening bleeding, selective arterial embolization by interventional radiology may be performed.