For a client diagnosed with epistaxis, which intervention would be included in the care plan?
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Nosebleeds are common. Most often they are a nuisance and not a true medical problem. But they can be both. Show Nosebleed care
When to seek emergency care
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. Nose Bleed Management and EpistaxisThis protocol serves as brief introduction to epistaxis treatment measures, many of which may only be temporizing in nature. For significant or uncontrollable epistaxis, it is recommended that patients immediately be seen by the appropriate emergency response/medical professionals in their area. see also: Facial Fracture Management Handbook; Epistaxis; Anterior Ethmoidal Artery Ligation; Endoscopic Sinus Surgery; Silver nitrate use and toxicity EpistaxisNew Latin, from Greek, from epistazein to drip on, to bleed at the nose again, from epi- + stazein to drip. EtiologyTraumatic: digital manipulation, abrasion (post nasal intubation, feeding tube, etc), fractures, etc *KTP laser of intra-nasal telangiectasias (HHT) (with or without Avastin injection) Some authors tend to classify epistaxis into Local and Systemic causes into which the above etiologies are then grouped. Pertinent AnatomyAnterior Bleeds: most bleeds tend to involve the region of the anterior nasal septum known as Kiesselbach's plexus or Little's area Posterior bleeds: identification of posterior bleed origin may be hard to perform without proper equipment. Systemic disease and neoplastic disease, as well as many of the causes listed above, may lead to significant alteration of intranasal anatomy. Patients may require significant consideration for treatment beyond the scope of this protocol. However, the emphasis on clinical exam and the determination of the appropriate treatment remain of paramount importance. Pre-Exam PreparationSECURING THE AIRWAY IS THE FIRST STEP IN TREATMENT
Each of these protective items should be requested prior to traveling to the ER or procured prior to treatment of patients on the wards or in clinic.
Examination- Identifying the location of the bleeding is absolutely paramount in epistaxis management. Once appropriate gowning and gloving have taken place, a head light and nasal speculum can often be utilized for initial examination. Treatment-Topical vasoconstrictors and digital pressure: May assist with temporizing or stopping some nose bleeds. Inspection for regions of concern and possible further treatment should be made according to presentation, history and clinical status of patient. Sometimes pledgets or a cotton ball soaked in vasoconstrictor and lidocaine can carefully be placed to slow bleeding anteriorly, and in the meantime an injection of ~1 cc of lidocaine 1% with 1:100,000 epinephrine into the greater palatine foramen bilaterally can be helpful in slowing the posterior supply's contribution. Use caution in patients with heart conditions, strongly consider placing on a monitor.
-Packing: A variety of packing may be available. If cauterization is unsuccessful, difficult to perform (in posterior bleeds for example), or if the patient is unstable then packing is indicated. The following is not an exhaustive list, but an overview of some of the more popular packs available -Foley catheter and gelatin-thrombin matrix combination (for posterior epistaxis)
 Image 1: As seen here, Surgicel comes in sheets that may be folded or cut to size for placement as needed.
Image 2: Nasopore in its packaging. Image 3: Nasopore in its packaging. UIHC Oto utilizes 8cm Extra Firm Nasopore with cutting to size performed on utilization.
Image 4: Floseal in packaging. Image 5: Floseal prepared in applicable matrix form. Syringe and applicator allow for some mid-posterior nasal application. Temporary packing: Foley catheter, lamb's wool, strip gauze, merocel, Rhinorocket, Rapid rhino.
Image 6: The 4.5 cm, 5.5 cm and 7.5 cm Rapid Rhino devices in their packaging. Image 7: The packaging and protective wrapper removed, all three devices pre-water soaked with no air added. Image 8: The devices post-water soak and with air added. Image 9: Cautery unit in UIHC ER ENT/Ophtho room. Nursing may not be familiar with its setup, so use these images as a guide for setting up suction cautery. Grounding pad inserts on bottom right and monopolar (suction) cautery on left. Note the blue adapter which allows for connection to the monopolar. If this adapter cannot be found someone may have to hold the monopolar wire in contact while you use it. Surgical InterventionSee also: Anterior Ethmoidal Artery Ligation
Post Procedure Prevention- Avoidance of digital manipulation and trauma. References
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