questions 2

Epistaxis

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Topic updated on 06/07/17 3:21pm

Snapshot
  •  A 14-year-old boy with no significant past medical history presents to the ED after being struck in the nose during a basketball game. There is frank blood coming from the nares.
Introduction
  • Nosebleeding that can arise from either the anterior or posterior circulation
    • anterior nosebleeds
      • involves bleeding from Kiesselbach's plexus
      • seen most commonly in children/adolescents
      • most commonly caused by trauma including nose picking
    • posterior nosebleeds
      • involves bleeding from Woodruff's plexus
      • seen most commonly in older adults with hypertension
      • not incited by trauma
  • Less common causes of epistaxis
    • nasopharyngeal angiofibroma
      • recurrent nosebleeds or obstruction without a history of trauma or blood dyscrasia
    • leukemia
    • blood dyscrasia
      • ex) vWD, hemophilia
    • Osler-Weber-Rendu syndrome
    • cocaine or other intranasal drug use
    • any cause of thrombocytopenia
      • ex) ITP
Presentation
  • Symptoms
    • bleeding from the nose
Evaluation
  • Assess vital signs if bleed is signficant
  • Majority do not require testing other than direct visualization
  • Have patient sit up with body tilted forward to allow blood to be passed out of the nares instead of passing posteriorly into the pharynx
 
Treatment
  • In anterior epistaxis, the following treatment protocol is required
    • compression
    • topical vasoconstriction
      • phenylephrine
    • chemical/electrocautery
    • nasal packing
    • arterial ligation or embolization
  • In posterior epistaxis, the following treatment protocol is required
    • blood pressure reduction
    • posterior nasal packing
    • arterial ligation of embolization
Prognosis, Prevention, and Complications
  • Patient advice for future anterior bleeds
    • compress cartilagenous portion of nose for 10-15 without releasing
    • avoid tissue paper placement inside the nose or swallowing blood
    • prevent with proper nasal hygiene which includes moisturization and avoidance of digital placement in the nose
  • Patient advice for future posterior bleeds
    • good long-term hypertension control
    • avoid tissue paper placement inside the nose or swallowing blood


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Qbank (2 Questions)

TAG
(M3.ET.14) A 14-year-old patient presents to the Emergency Department (ED) with an intractable nosebleed. Pinching of the nose has failed to stop the bleed. In the ED a topical vasoconstrictor is tried but also fails to stop the bleeding. What is the appropriate next step? Topic Review Topic

1. Observation
2. Anterior nasal packing
3. Posterior nasal packing
4. Electrocautery of Kiesselbach's plexus
5. Electrocautery of Woodruff's plexus

PREFERRED RESPONSE ▶
TAG
(M2.ET.4828) A 16-year-old boy presents to the emergency department due to right-sided hearing loss, headache, and nasal bleeding. He reports that for the past few months he has found it difficult to breathe through his nose and has had nasal drainage. He also states that he has not been able to stop his nose from bleeding for the last few hours. His right-sided hearing loss began around the same time as his difficulty with nasal breathing. He denies any history of trauma to the nose, uncontrollable bleeding, and easy bruising. His family history is unremarkable. His temperature is 99°F (37.2°C), blood pressure is 112/67 mmHg, pulse is 95/min, and respirations are 20/min with an oxygen saturation of 99%. On physical examination, the patient appears anxious. There is an amber fluid collection in the right ear appreciated on otoscopy. An intranasal reddish-blue mass in the lateral wall of the nasal cavity is noted upon inspection. Which of the following is the best next step in management? Topic Review Topic

1. Biopsy
2. Intranasal phenylephrine
3. Surgical resection
4. Radiotherapy
5. Computerized tomography scan of the head

PREFERRED RESPONSE ▶


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