EPISTAXIS

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  <B>EPISTAXIS</B></div> <div> <IMG SRC="001f4010.png" border=0 width="500" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> EPISTAXIS</div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B><IMG SRC="01e61e00.jpg" border=0 width="353" height="480" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="01fe09d0.jpg" border=0 width="224" height="157" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="02018aa0.png" border=0 width="280" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="021e29d0.png" border=0 width="226" height="157" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="02276800.jpg" border=0 width="118" height="128" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="024e39c0.png" border=0 width="227" height="156" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="025eba30.png" border=0 width="235" height="163" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="026fa750.png" border=0 width="250" height="117" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="027fa800.png" border=0 width="250" height="128" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="028b4fa0.png" border=0 width="180" height="250" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="02936ce0.png" border=0 width="310" height="206" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> <B>Bleeding from the nose</B><FONT SIZE="3" COLOR="#FFFFCC" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bleeding from inside the nose is a common complaint presenting an emergency.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Epistaxis is often a frightening sight to the patient and the attendants, especially if the patient is a kid. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There are a variety of causes which can lead to bleeding from the nose. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Children often have a few isolated nosebleeds, but repeated nosebleeds will mean a trip to the doctor.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Mild trauma is the usual cause, as the nose is well supplied with blood vessels and bleeds easily. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Falls, fistfights, vigorous nose rubbing, nose blowing or nose picking are typical causes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bleeding disorders cause less than 5% of nosebleeds.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epistaxis is classified as anterior or posterior based upon the primary bleeding site.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Hemorrhage is most commonly anterior, originating from the nasal septum. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A common source of anterior epistaxis is Kiesselbach plexus, an anastomotic network of vessels on the anterior portion of the septum just superior to the posterior end of the nasal vestibule.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Bleeding also may originate anterior to the inferior turbinate. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Posterior hemorrhage originates in the posterior nasal cavity or nasopharynx, usually below the posterior half of the inferior turbinate or roof of the nasal cavity. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Control of significant bleeding or hemodynamic instability should take precedence over a lengthy history.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Duration of hemorrhage and side of initial bleeding should be noted.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">History of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>, hypertension, hepatic or other systemic disease, easy bruising, or prolonged bleeding after minor surgical procedures should be sought. Recurrent episodes of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>, even if self-limited, should raise suspicion for significant nasal pathology.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Use of medications, especially aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, heparin, ticlopidine, and dipyridamole should be documented, as these not only predispose to <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> but make treatment more difficult.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nausea is a possible symptom.</div> <div> <B>Physical: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Approximately 90% of nosebleeds can be visualized in the anterior portion of nasopharynx.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Massive <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> may be confused with hemoptysis or hematemesis. Blood dripping from posterior nasopharynx confirms a nasal source.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Perform a thorough and methodical examination of nasal cavity.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blowing the nose removes clots permitting a better exam and decreases effects of local fibrinolysis. Application of a vasoconstrictor prior to the exam may reduce hemorrhage and help to pinpoint the precise bleeding site. Topical application of a local anesthetic reduces pain associated with the exam and nasal packing.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gently insert a nasal speculum and spread the naris vertically. This permits visualization of most anterior bleeding sources.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A posterior source is suggested by failure to visualize an anterior source, by hemorrhage from both nares, and by visualization of blood draining in posterior pharynx</div> <bR> <div> <B>Frequency: </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In the US: </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" >Epistaxis</FONT> occurs in 1 of 7 people. </div> <div> <B>Mortality/Morbidity: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mortality is rare and usually is due to complications from hypovolemia, with severe hemorrhage or underlying disease states.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Increased morbidity is associated with nasal packing. Posterior packing can potentially cause airway compromise. Packing in any location may lead to infection.</div> <div> <B>Sex: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">No sexual predilection exists.</div> <div> <B>Age: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bimodal incidence exists, with peaks in those aged 2-10 years and 50-80 years.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nasal hemorrhage occurs most commonly during colder months and in dry colder climates</div> <bR> <bR> <bR> <div> <B>Symptoms</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Frequency can vary from once a month to several times a day. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">With heavy bleeding, blood may be swallowed and produce vomiting of blood or black tarry bowel motions. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Examining the nose will show a red, raw area with fresh clots or old crusted blood. </div> <div> <B>Investigations</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A blood test to check for anaemia, which may not be evident until 12 hours later. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Further testing for blood disorders is not needed except where there is a family history of a bleeding disorder, bleeding at other sites, a nosebleed lasting longer than 30 minutes or the blood will not clot, a nosebleed in a child under 2 years old or anaemia due to <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>. </div> <div> <B>Causes: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most cases of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> do not have an easily identifiable cause.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Local trauma (ie, nose-picking) is the most common cause, followed by facial trauma, foreign bodies, nasal or sinus infections, and prolonged inhalation of dry air. A disturbance of normal nasal airflow, as occurs with a deviated nasal septum, also may be a cause of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Iatrogenic causes include nasogastric and nasotracheal intubation.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Children usually present with <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> due to local irritation or recent upper respiratory infection (URI).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients with AIDS may have splenomegaly, thrombocytopenia, or platelet disorders.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertension</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Despite a strong association with nasal hemorrhage, elevated blood pressure is rarely a direct cause of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vascular fragility secondary to chronic hypertension probably increases occurrence of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> in these patients.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vascular abnormalities</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sclerotic vessels</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hereditary hemorrhagic telangiectasia</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Arteriovenous malformation</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neoplasm</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Coagulopathy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Septal perforation, deviation</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Endometriosis</div> <bR> <bR> <bR> <div> <B>Other possibilities</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Allergic Rhinits causes swollen lining in the nose prone to <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>. Nasal smear for eosinophils confirms the diagnosis. Oral medication or nasal sprays may be helpful. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chronic bleeding disorder may present as nosebleeds. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Medications such as aspirin or warfarin may cause <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Abnormal arrangement of blood vessels in the nose (telangectasia, haemangiomas or varicoities) may predispose to nosebleeds. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">High blood pressure. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nasopharyngeal angiofibroma is a tumor of adolescent males and often presents as <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>. Bleeding confined to the back of the throat makes the elimination of this diagnosis mandatory. The diagnosis can be made by taking lateral soft tissue x-rays. </div> <div> <B>Complication</B></div> <div> Unless an underlying bleeding disorder exists, the only complication of nosebleed is mild anaemia. Anaemia rarely occurs and unusual responds to iron supplements</div> <bR> <div> <B>Local causes</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Finger nail trauma due to excessive nose picking. This is the most common cause among the children. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Trauma to nose due to road traffic accident or being hit on the nose by a ball or fist. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fracture of the nasal bones. </div> <div> <B>Infections</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Viral rhinitis (infection of the nose). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acute sinusitis </div> <div> <B>Others</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Foreign bodies in nose </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Deviation of the nasal septum </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Atmospheric changes such as sudden movement to high altitudes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Any growth in the nasal cavity, like polyps, benign or malignant tumors. </div> <div> <B>General Causes</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypertension – commonly seen in old age </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Heart diseases </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pregnancy </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bleeding disorders – when the patient has a deficiency in the system responsible for control of bleeding there is an abnormal tendency to bleed. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Drugs- like excessive use of analgesics for pain. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acute general infections like typhoid, pneumonia, malaria, dengue fever, measles etc. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Idiopathic - at times the cause of bleeding may not be clear</div> <bR> <div> <IMG SRC="01be47d0.jpg" border=0 width="228" height="381" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="01c241b0.png" border=0 width="292" height="283" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epistaxis typically originates from the nasal septum when the nasal mucosa overlying a dilated blood vessel is injured. Epistaxis may, however, signal an underlying condition such as a coagulation disorder, so the treating physician must be alert for signs of serious illness. Most nosebleeds stop spontaneously within 5 minutes with or without pressure to the forehead, nose, or upper lip. Some require anterior nasal packing. A few arise from posterior arteries and require anterior-posterior nasal packing and a referral.</div> <div> <FONT SIZE="5" COLOR="#FFFFCC" FACE="Arial" ><B><IMG BORDER="0" SRC="Symb075c00b70168ccffff00.png" HEIGHT="24" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A</B></FONT>lthough a bleeding nose may seem merely a bloody nuisance, it can sometimes be a sign of a serious condition such as coagulopathy or cancer. Sports-related trauma and various other causes make <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> a common condition in active-and apparently healthy-people. Physicians must not only be adept at pinpointing the site of bleeding and stanching the flow, but also must be alert to potentially serious causes.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c8ccffff00.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Causes of Bleeding</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The blood supply to the nose (figure 1: not shown) originates from two sources: the internal and external carotid arteries. It is profuse and diffuse, with many arterial and venous anastomoses.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The vast majority of nosebleeds originate from the nasal septum and erupt when the relatively thin nasal mucosa overlying a dilated septal vessel dries, scabs, and falls (or is picked) off.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Trauma is the second most common cause of nosebleeds. A force sufficient to deform the nasal skeletal structures can cause mucosal disruption and bleeding anteriorly on the septum, laterally along the nasal walls, or, with Le Fort's fracture, posteriorly at the sphenopalatine or superiorly at the ethmoid vessels. Posterior <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>, though rare, is the third most common type of nosebleed. Its etiology is still debated.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nosebleeds may also herald underlying illness (1,2). The astute physician, therefore, must recognize that the presentation of such nosebleeds is in one way or another atypical.</div> <bR> <div> <B>Lab Studies: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The following lab studies are recommended in the presence of major bleeding or if a coagulopathy is suspected:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hematocrit, type and cross - Obtain these if a history of persistent heavy bleeding is present.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complete blood count (CBC) - Obtain if a history of recurrent <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>, a platelet disorder, or neoplasia is present.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bleeding time - An excellent screen if suspicion of a bleeding disorder is present.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">International normalized ratio (INR)/activated partial thromboplastin time (aPTT) - Obtain if the patient is taking warfarin or if liver disease is suspected.</div> <div> <B>Imaging Studies: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sinus films (rarely)</div> <div> <B>Other Tests: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CT scan and/or nasopharyngoscopy if a tumor is the suspected cause of bleeding</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Angiography (rarely)</div> <bR> <bR> <bR> <div> Targeted Treatment</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Epistaxis can usually be managed with a step-by-step approach (figure 2: not shown). The vast majority of spontaneous or traumatic nosebleeds in people who have no underlying coagulopathy stop on their own with or without ice to the forehead, pressure to the upper lip, or pinching of the nostrils against the septum. Those that continue to bleed after 3 or 4 minutes can be controlled by one of two approaches.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The easiest is applying pressure to the bleeding site with anterior nasal packing (table 1). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">To do this, the physician topically vasoconstricts and anesthetizes the nasal mucosa. Bacitracin or a similar ointment is applied to one of the commercial anterior nasal packs (Xomed, Inc, Jacksonville, Florida; Shipert Medical Technology, Englewood, California).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The tampon is inserted with a firm grasp, using a hemostat or bayonet forceps. The tampon will swell and compress the bleeding site. Layered, 1/2-in. gauze with petrolatum is a rough but effective alternative to the tampon. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099ffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A second approach is to stop the bleeding with vasoconstrictors such as topical oxymetazoline hydrochloride, cocaine, or epinephrine 1:100,000, and then to cauterize the bleeding site with silver nitrate or electric cautery.</div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="750" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 20 WIDTH="740"><div> <B>Table 1. Materials Needed for an Anterior Nasal Pack</B> </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 129 WIDTH="740"><div> Layered 1/2-in. gauze with petrolatum</div> <div> Expandable cellulose intranasal tampons</div> <div> Gelfoam pledget</div> <div> Gelfoam pledget wrapped in Surgicel</div> <div> Collagen hemostat</div> <div> Nasal tampon (eg, Rhinorocket, Fast-Pak)</div> <bR> </tD> </tR> </TABLE></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff6600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The rare and more serious posterior nosebleed requires an anterior-posterior (AP) pack and referral to an otolaryngologist (3).</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff6600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Commercial balloons such as the Epistat (Xomed, Inc) and Nasostat (Sparta, Pleasanton, California) are the most commonly used devices. A Foley balloon catheter with anterior gauze packing is also effective.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff6600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The most secure AP pack is a 4" x 4" gauze sponge pulled against the posterior choana with a transnasal, 0 silk suture, combined with anterior layered gauze packing, though it is the most difficult and messy to insert. Table 2 shows the contents of a complete </B><B>epistaxis</B><B> tray.</B></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="708" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 20 WIDTH="698"><div> <B>Table 2. </B><B>Epistaxis</B><B> Equipment</B><B> </B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FFFF HEIGHT= 278 WIDTH="698"><div> <B>4" x 4" gauze sponge</B></div> <div> <B>1 x 6 cm cottonoids (neurosurgical gauze patties)</B></div> <div> <B>Merocel nasal packing with airway</B></div> <div> <B>Gelfoam pledget</B></div> <div> <B>Expandable cellulose intranasal tampons</B></div> <div> <B>Surgicel</B></div> <div> <B>Nasal speculum</B></div> <div> <B>Frazier suction cannula</B></div> <div> <B>Intranasal balloon (eg, Epistat, Nasostat)</B></div> <div> <B>0 silk suture</B></div> <div> <B>Layered 1/2 in. gauze with petrolatum</B></div> <div> <B>10-mL syringe</B></div> <div> <B>Bayonet forceps</B></div> <div> <B>#16 Foley balloon catheter</B></div> <bR> </tD> </tR> </TABLE></div> <div> <FONT SIZE="3" COLOR="#FFFFCC" FACE="Arial" ><IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The following examples are hypothetical composite cases that highlight various underlying causes of </FONT>epistaxis, al<FONT SIZE="3" COLOR="#FFFFCC" FACE="Arial" >ong with targeted treatment strategies.</FONT></div> <bR> <bR> <bR> <bR> <bR> <div> Case 1: Easily Controlled Bleeding</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 5-year-old male soccer player invariably trots over to the bench with blood pouring from his nose as halftime approaches. The bleeding is always controlled within 2 to 3 minutes by applying ice to his forehead and digital pressure to his upper lip and the base of his nose. Further history reveals that the patient frequently develops spontaneous <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> at night, and his pillow is often bloodstained in the morning. All of his witnessed nosebleeds have spontaneously ceased in less than 5 minutes. Physical exam shows crusting over the anterior septum.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The diagnosis--a common one--is nose picking. This little boy constantly picks his nose, which leads to scab formation and bleeding from the underlying dilated vessels.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Treatment is twofold. First, petrolatum or a bacitracin ointment should be applied to the anterior naris twice a day. Antibiotic ointments are discouraged because of the risk of inducing allergic reaction.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The second part of treatment is to discourage the nose picking. It is easy enough to tell the child not to pick his nose during the day. The problem is that many children pick their noses unconsciously at night, hence the bloodstained pillow. The easiest way to stop this practice is to place a glove on the child's hand for sleeping. Baseball batting gloves, gardening gloves, and socks all work well. They simply add enough bulk to the child's fingers so they no longer fit inside the nostril.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">All nosebleeds must be looked on as a possible sign of underlying coagulopathy. This could be the first symptom of hemophilia or leukemia. Had the bleeding persisted for more than 5 minutes or not responded to treatment, a coagulation workup would have been required (2).</div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <div> Case 2: Profuse Nosebleed</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 12-year-old football player jogs to the sidelines with an absolutely horrendous nosebleed after a particularly jarring tackle. Blood pours out anteriorly, and he spits more out of his mouth. The bleeding stops as suddenly as it began. His jersey is soaked, and an estimated 200 mL of blood is lost.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is a classic juvenile angiofibroma. These highly vascular tumors arise in the nasal pharynx, typically in pubescent males. They commonly present with a sentinel nosebleed that is typically voluminous, rapid, and very different from that seen in anterior septal bleeding.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Had the bleeding not stopped spontaneously, an anterior nasal pack would not have tamponaded the bleeding site in the nasal pharynx. The only means of stopping the bleeding would have been an AP pack.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">AP tamponade is best performed in the field by establishing the posterior tamponade with a Foley balloon. The Foley is passed through the nose and into the nasopharynx. The balloon is filled with water and then pulled anteriorly, and thus is held in place against the posterior choana by anterior traction. The anterior naris is then obstructed, either with layered gauze packing or with an anterior balloon. Holding the Foley anteriorly is no small feat. If available, an umbilical cord clip or safety pin may work as well as any other device. Immediate referral for angiography and resection is then made.</div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <div> Case 3: Trauma-Induced <FONT SIZE="2" COLOR="#800000" FACE="Arial" >Epistaxis</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 14-year-old basketball player is struck in the nose by an opponent's elbow while grabbing a rebound. She runs to the bench holding her nose, which is now pouring blood.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The recommended treatment is to have the player sit down and lean forward. This is particularly necessary with basketball players because most of them are so tall that the average physician can barely reach the player's nose without standing on a stool or having the player sit. Pressure applied externally to the nose, if tolerated, will generally tamponade the bleeding, which stops either because of the pressure or of its own accord. (External pressure is unlikely to compound the injury.) Fractured noses will bleed from a mucosal tear inside the nose. While this bleeding is impressive and generally anterior, it is not overwhelming and usually stops spontaneously.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If the nose is crooked or flattened, it is safe to say it has been fractured and reduction is required. If the nose is cosmetically unchanged, it does not matter whether it is broken or not; no reduction will be required. Nasal x-rays are never requested. They are right only half the time and never contribute to diagnosis or treatment.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Once the bleeding has stopped, the nose should be inspected to rule out a septal hematoma. Typically, a septal hematoma is uncomfortable, will cause nasal obstruction, and is not easy to diagnose. It is seen as a smooth bulging of the septum, typically obstructing the airway. Gentle palpation reveals it is soft and compressible, very unlike a normal septum. If a hematoma is suspected, the patient should be referred to a head and neck surgeon for needle aspiration or cruciate incision and drainage. Both of these procedures are followed by a firm anterior layered gauze pack to tamponade the bleeding and keep the septal mucosa pressed firmly against the cartilage.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Generally speaking, if a person is hit in the nose forcefully enough to cause bleeding, a fracture has occurred. If the nose is straight, return to play is a judgment call. If the nose has been broken, any repeat trauma before the fracture has fully healed will more easily fracture and displace the nose. Hence, the most conservative approach would be to remove the player from the field for 6 weeks.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">But given our ability to reduce nasal fractures and given the importance of continuing play, a strong argument can be made to resume play the next day, assuming the patient feels well and his or her nose is not grossly swollen and obstructing vision. Early return to play with or without nose protection carries risk of refracture and impaired nasal function. The risk, however, is small. Most fractures (including refractures) can be repaired, so if play is important, the risk-benefit ratio is reasonable.</div> <bR> <bR> <bR> <bR> <bR> <div> Case 4: Continual Hemorrhage</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 16-year-old female softball player is forcefully tagged while sliding into second base. She pops up with her nose streaming blood anteriorly and walks to the dugout. Ice is applied to her forehead, pressure is applied to her upper lip, and her nostrils are squeezed shut, but the bleeding persists.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">With her nostrils squeezed shut, the blood runs down the back of her throat. The nostril pinching is therefore discontinued and the nose allowed to bleed anteriorly. The bleeding is unilateral. A nasal balloon is inserted and inflated. The patient is brought to the emergency room for further evaluation.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The patient had no previous bleeding and denies taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), birth control pills, or any other medication. Family history reveals a maternal aunt with some unknown recurrent nosebleed disorder. The nasal tampon is removed and the bleeding immediately resumes. The nasal tampon is reinserted and the bleeding is controlled.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A complete blood count and coagulation profile are ordered. The hematocrit returns at 36% with a hemoglobin of 12 g/dL, and the prothrombin time, partial thromboplastin time, quantitative platelet count, and bleeding time (Ivy method) are all normal. The patient is discharged with instructions to return the next day.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The nasal tampon is again removed the following day, and this time the bleeding does not resume. The patient's nose is filled with bacitracin ointment, and a cotton pledget saturated in bacitracin ointment is placed in the anterior naris. The patient is instructed to change the pledget two to three times a day for the next 5 days. This moist anterior nasal plug is the key to preventing rebleeding and should be used for 3 to 7 days after all significant anterior nose bleeds.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The patient returns after 5 days. She has no recurrent bleeding and her nose is clean, but on close inspection multiple telangiectasia lesions are noted on the nasal mucosa. Further examination reveals telangiectasia also on the lips and dorsal tongue. Diagnosis is made of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)--an autosomal dominant illness. The patient is referred to a head and neck surgeon. Her case highlights the fact that the single best predictor of coagulopathy is family history.</div> <bR> <bR> <bR> <bR> <bR> <div> Case 5: Prolonged Bleeding Time</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 24-year-old high school baseball coach has recurrent <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>. Bleeding can occur anytime, but is most annoying during baseball games. It is always controlled by pinching the nostrils--but it typically takes 10 to 15 minutes to fully control. The coach denies aspirin intake but uses an NSAID on a regular basis for the pains of an old football injury. The patient has no other underlying illnesses, and a recent physical examination was normal.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This case is unusual for the time it takes the bleeding to stop. The patient is taken off the NSAID. At first he has fewer nosebleeds, but during a playoff game his nose again bleeds, and again takes 10 to 15 minutes of direct pressure to control. After the game, his nose is examined and no lesions are seen. He has one or two visible vessels on his nasal septum, but no crusting and no obvious bleeding site.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A complete blood count and coagulation profiles are obtained. The hematocrit is 45% with a hemoglobin of 15 g/dL. Prothrombin time, partial thromboplastin time, and platelet count are all normal. Bleeding time with the Ivy method is prolonged. This test is repeated and is again prolonged. The patient is referred to a hematologist, and a diagnosis of von Willebrand's disease, one of the more commonly inherited coagulation disorders, is made. The key to this diagnosis was the prolonged nasal bleeding time, even when the patient was taken off the NSAID.</div> <bR> <bR> <bR> <bR> <bR> <bR> <div> Case 6: Recurrent Trickle</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 36-year-old physician for the local college football team reports to his primary care physician requesting a referral to a hematologist for recurrent <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT>. The primary care physician, however, insists on seeing him first. The patient gives no family history of bleeding and has undergone surgery in the past with no difficulties. He denies taking any medications.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The bleeding occurs once or twice a day, and although it tends to be only a trickle, it has recently become a repeatedly annoying occurrence. On physical examination, crusting is evident on the septum, and on closer inspection a septal perforation is noted. The patient denies nasal trauma.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When questioned directly, the patient admits to a long history of cocaine use. Septal perforation is a common problem with repeated cocaine application to the nose. The typical symptoms are crusting, whistling, and bleeding. Most cocaine users know this to be a complication, and few will seek medical help unless they have stopped their cocaine habit and are looking to have their perforation repaired.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Perforations do occur from other causes such as repeated nose picking, nasal surgery, and repeated septal cauterizations for nosebleeds. Septal perforations, particularly the smaller ones, can be repaired. There is no sense in repairing them, though, unless the patient has clearly discontinued cocaine use. The crusting and bleeding from septal perforations is best controlled by anterior nasal application of ointments, as in case 1. The crusting is further alleviated by irrigating the nose with hypotonic pulsatile saline. The saline is delivered with a special nasal adapter using an adjustable Waterpik (Teledyne Waterpik, Fort Collins, Colorado). Two commercially available nasal adapters are the Ethicare (Ethicare Products, Fort Lauderdale, Florida) and the Grossan Nasal Irrigator (HydroMed, Inc, Los Angeles).</div> <bR> <bR> <bR> <bR> <bR> <bR> <div> Case 7: New-Onset <FONT SIZE="2" COLOR="#800000" FACE="Arial" >Epistaxis</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 45-year-old runner seeks care first thing Monday morning. While running a half marathon the day before, he developed a nosebleed that he could not control and that forced him out of the race. He has no family history of nasal bleeding and has not had problems with bleeding or <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> in the past.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">During a physical examination 6 months ago, the patient had elevated cholesterol and mildly elevated blood pressure. He was given appropriate instructions for diet and began serious running in an effort to lose weight and further reduce the cholesterol. The running caused the usual lower-extremity discomfort. In part as a precautionary measure against arteriosclerotic heart disease and in part as an analgesic, the patient self medicated with one adult aspirin daily. On physical exam the patient has crusting over an obvious bleeding site within the nose.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The patient's nose is filled with bacitracin ointment and then occluded with a small piece of cotton. He is advised to replace the ointment-saturated cotton pledget two to three times a day for 5 days and is advised to discontinue the aspirin for this period. Based on personal experience, the most common cause of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> in a 40-year-old healthy person is pharmacologic coagulopathy, and the most common offender is aspirin.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The patient returns the following Monday, and his nose exam is normal. He is counseled to use 80 mg of aspirin daily and advised that this is adequate cardiac protection and far less likely to cause recurrent nosebleeds.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c8ccffff00.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Case 8: Serosanguineous Discharge</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 75-year-old tennis player, during her annual physical exam, says that for the past 3 months she has been experiencing a daily serosanguineous nasal discharge.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">No other history is necessary. The diagnosis is a nasal or paranasal sinus cancer until ruled out. The recommended workup is a nasal endoscopy. If no tumor is seen, a sinus computed tomography scan with contrast is required.</div> <bR> <bR> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700c8ccffff00.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Keeping Alert for the Unusual</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most nosebleeds are controlled with direct pressure to the glabella, nasal alae, or upper lip and columella. More persistent anterior nosebleeds are controlled with commercially available balloons and tampons. The occasional severe nosebleed requires anterior-posterior tamponade and referral to a specialist. The sports medicine physician must remain vigilant for the uncommon underlying coagulopathies and tumors.</div> <bR> <bR> <bR> <bR> <bR> <div> <B>Emergency Department Care: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Upon initial arrival to ED, instruct patients to grasp and pinch entire nose maintaining continuous pressure for at least 10 minutes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gowns, gloves, and protective eyewear should be worn. Adequate light is best provided by a headlamp with an adjustable narrow beam. Patient should be positioned comfortably, holding a basin under chin.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">As always, address ABCs. Severe <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> may require endotracheal intubation. Rapid control of massive bleeding is best secured with an <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> balloon or Foley catheter, as outlined below.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients with significant hemorrhage should receive an IV line and crystalloid infusion, as well as continuous cardiac monitoring and pulse oximetry. Patients frequently present with an elevated blood pressure; however, a significant reduction usually can be obtained with analgesia and mild sedation alone. Specific antihypertensive therapy rarely is required and should be avoided in the setting of significant hemorrhage.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Insert pledgets soaked with an anesthetic-vasoconstrictor solution into nasal cavity to anesthetize and shrink nasal mucosa. Soak pledgets in 4% topical cocaine solution or a solution of 4% lidocaine and topical epinephrine (1:10,000) and place them into nasal cavity. Allow them to remain in place for 10-15 minutes.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If a bleeding point is easily identified, gentle chemical cautery may be performed after adequate topical anesthesia. The tip of a silver nitrate stick is rolled over mucosa until a grey eschar forms. Only one side of septum should be cauterized at a time, to avoid septal necrosis or perforation. In order to be effective, cautery should be performed after bleeding has been controlled.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If attempts to control hemorrhage with pressure or cautery fails, nose should be packed. Alternatives include traditional nasal packing, an <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> balloon, or a prefabricated nasal sponge.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Traditional (Vaseline gauze) packing: This is the traditional method of anterior nasal packing. It commonly is performed incorrectly, using an insufficient amount of packing placed primarily in the anterior naris. Placed in this way, the gauze serves as a plug rather than a hemostatic pack. Physicians inexperienced in proper placement of a gauze pack should consider use of a nasal tampon or balloon. The proper technique for placement of a gauze pack is as follows: </div> <div> Grasp gauze ribbon, about 6 inches from its end, with bayonet forceps. Place in the nasal cavity as far back as possible, ensuring that the free end protrudes from the nose. On the first pass, the gauze is pressed onto the floor of nasopharynx with closed bayonets. </div> <div> Then grasp ribbon about 4-5 inches from nasal alae and reposition nasal speculum so that lower blade holds the ribbon against lower border of nasal alae. Bring a second strip into nose and press downward. </div> <div> Continue this process, layering gauze from inferior to superior until naris is completely packed. Both ends of ribbon must protrude from naris and should be secured with tape. If this does not stop bleeding, consider bilateral nasal packing. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Compressed sponge (Merocel): Trim Merocel foam to fit snugly through naris and place it along floor of nasal cavity. Once wet with blood or a small amount of saline, it expands to fill the nasal cavity and tamponade bleeding.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anterior <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> balloons: Balloons come in anterior (single balloon) or anterior-posterior (double balloon) models. Cover an anterior catheter with antibiotic ointment, insert it along floor of nasal cavity, and inflate slowly with sterile water until bleeding stops.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Posterior <FONT SIZE="3" COLOR="#800000" FACE="Arial" >epistaxis</FONT> balloons </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">After passing through the naris and into posterior nasal cavity, inflate balloon with 4-5 mL sterile water and gently pull forward to fit snugly in posterior choana. After bleeding into posterior pharynx has been controlled, fill anterior balloon with saline until bleeding completely stops. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avoid over inflation because pressure necrosis or damage to septum may result. Record the amount of fluid placed in each balloon. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If a Foley catheter is used, place a 12-16 French catheter with a 30 cc balloon into the nose along floor of nasopharynx, until the tip is visible in the posterior pharynx. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Then slowly inflate balloon with 15 mL saline, pull it anteriorly until it firmly sets against posterior choanae, and secure it in place with an umbilical clamp. Use a buttress clamp with cotton gauze to avoid pressure necrosis on nasal alae or columella. Finally, an anterior nasal pack should be placed.</div> <div> <B>Consultations: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Manage bleeding requiring posterior packing with ear, nose, and throat (ENT) consultation. Due to multiple possible complications, admission is required, usually in a monitored setting.</div> <bR> <bR> <bR> <bR> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000080 HEIGHT= 20 WIDTH="23"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="23" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER BGCOLOR=#000080 WIDTH="310"><div> <B>MEDICATION </B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#000080 WIDTH="285"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="285" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients discharged with anterior packing should receive follow-up with ENT within 48-72 h. Nasal packing prevents drainage of sinuses. Consider placing patients on a broad-spectrum antibiotic to cover all likely pathogens in the context of the clinical setting. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Oral analgesics should be prescribed to assure quality patient care.</div> <bR> <bR> <bR> <div> Drug Category: <I>Antibiotics</I> <FONT SIZE="3" COLOR="#FFFFCC" FACE="arial" >- Therapy must cover all likely pathogens in the context of the clinical setting. Consider placing patients on a penicillin or first-generation cephalosporin. </FONT></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1041" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 35 WIDTH="186"><div> <B>Drug Name</B></div> <bR> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> Amoxicillin (Biomox, Trimox)- Treats infections caused by susceptible organisms and as prophylaxis in minor procedures. </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="186"><div> <B>Adult Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="840"><div> 250-500 mg PO q8h; not to exceed 3 g/d </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="186"><div> <B>Pediatric Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="840"><div> 20-50 mg/kg/d PO q8h </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 ><NOBR><div> <B>Contraindications</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="840"><div> Documented hypersensitivity </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="186"><div> <B>Interactions </B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="840"><div> Reduces the efficacy of oral contraceptives </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="186"><div> <B>Pregnancy</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="840"><div> B - Usually safe but benefits must outweigh the risks. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="186"><div> <B>Precautions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="840"><div> Adjust dose in renal impairment</div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1044" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="183"><div> <B>Drug Name</B></div> <bR> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="846"><div> Cephalexin (Keflex)- First-generation cephalosporin, which is primarily active against skin flora. Used for skin structure coverage and as prophylaxis in minor procedures. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Adult Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="846"><div> 250-1000 mg PO q6h; not to exceed 4 g/d </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Pediatric Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="846"><div> 25-50 mg/kg/d PO q6h; not to exceed 3 g/d </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 ><NOBR><div> <B>Contraindications</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="846"><div> Documented hypersensitivity </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Interactions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="846"><div> Coadministration with aminoglycosides increase nephrotoxic potential </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Pregnancy</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="846"><div> B - Usually safe but benefits must outweigh the risks. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Precautions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="846"><div> Adjust dose in renal impairment</div> </tD> </tR> </TABLE></div> <div> Drug Category: <I>Analgesics (avoid NSAIDs and aspirin)</I> <FONT SIZE="3" COLOR="#FFFFCC" FACE="arial" >- Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Most analgesics have sedating properties, which are beneficial for patients who have sustained painful skin lesions. </FONT></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1059" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="183"><div> <B>Drug Name</B></div> <bR> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="861"><div> Acetaminophen (Tylenol, Aspirin Free Anacin, Feverall)- DOC for treating pain in patients with documented hypersensitivity to aspirin, upper GI disease, or who take oral anticoagulants. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Adult Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="861"><div> 325-650 mg PO q4-6h or 1000 mg PO tid/qid; not to exceed 4 g/d </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="183"><div> <B>Pediatric Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="861"><div> <12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d</div> <div> >12 years: 650 mg PO q4h; not to exceed 5 doses in 24 h </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 ><NOBR><div> <B>Contraindications</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="861"><div> Documented hypersensitivity </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="183"><div> <B>Interactions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="861"><div> Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="183"><div> <B>Pregnancy</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="861"><div> B - Usually safe but benefits must outweigh the risks. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 57 WIDTH="183"><div> <B>Precautions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="861"><div> Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose</div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1069" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 35 WIDTH="184"><div> <B>Drug Name</B></div> <bR> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div> Hydrocodone bitartrate and acetaminophen (Vicodin ES)- For the relief of moderate to severe pain. </div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="184"><div> <B>Adult Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="870"><div> 1-2 tabs or caps PO q4-6h prn for pain </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 73 WIDTH="184"><div> <B>Pediatric Dose</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="870"><div> <12 years: Based on acetaminophen dose of 10-15 g/kg/dose q4-6h prn; not to exceed 10 mg/dose of hydrocodone bitartrate or 2.6 g/d of acetaminophen</div> <div> >12 years: Based on acetaminophen dose of 750 mg q4h; not to exceed 5 doses q24h</div> <bR> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 ><NOBR><div> <B>Contraindications</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="870"><div> Documented hypersensitivity </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 38 WIDTH="184"><div> <B>Interactions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="870"><div> Phenothiazines may decrease the analgesic effects; toxicity increases with coadministration of CNS depressants or tricyclic antidepressants </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="184"><div> <B>Pregnancy</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="870"><div> C - Safety for use during pregnancy has not been established. </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="184"><div> <B>Precautions</B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="870"><div> Tablets contain metabisulfite, which may cause allergic reactions</div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000080 HEIGHT= 20 WIDTH="23"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="23" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER BGCOLOR=#000080 WIDTH="310"><div> <B>FOLLOW-UP </B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#000080 WIDTH="285"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="285" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> <B>Further Inpatient Care: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Admit patients with posterior packing. Elderly patients or patients with cardiac disorders or chronic obstructive pulmonary disease (COPD) should receive supplemental oxygen and should be admitted to a monitored setting.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Significant or uncontrolled bleeding from a posterior site may require operative management. At most centers, selective arterial embolization has become treatment of choice for severe <FONT SIZE="3" COLOR="#800000" FACE="arial" >epistaxis</FONT>.</div> <div> <B>Further Outpatient Care: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients discharged with anterior packing should receive follow-up with ENT within 48-72 hours. Nasal packing prevents drainage of sinuses.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Consider placing patients on a penicillin or first-generation cephalosporin. Oral analgesics also should be prescribed.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Inform patient to avoid aspirin, aspirin containing products, or NSAIDs.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Give patient specific written follow-up instructions.</div> <div> <B>Complications: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sinusitis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Septal hematoma/perforation</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">External nasal deformity</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mucosal pressure necrosis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vasovagal episode</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Balloon migration</div> <div> <B>Prognosis: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Excellent, with proper treatment</div> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000080 HEIGHT= 20 WIDTH="23"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="23" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER BGCOLOR=#000080 WIDTH="310"><div> <B>MISCELLANEOUS </B></div> </tD> <tD VALIGN=CENTER BGCOLOR=#000080 WIDTH="285"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="285" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> <B>Medical/Legal Pitfalls: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Posterior nasal packing is particularly uncomfortable for the patient and promotes hypoxia and hypoventilation. Failure to admit and appropriately monitor all patients who require posterior packing may result in significant mortality.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Attempts at nasal packing may result in significant slowing but not cessation of hemorrhage. Failure to completely control hemorrhage is an absolute indication for ENT consultation in the ED.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tumors or other serious pathology are infrequent causes of</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000008000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">epistaxis<FONT SIZE="3" COLOR="#FFFFCC" FACE="arial" >. However, all patients who present with </FONT>epistaxis<FONT SIZE="3" COLOR="#FFFFCC" FACE="arial" > should have follow-up care arranged with an ENT surgeon for a complete nasopharyngeal examination.</FONT></div> <div> <FONT SIZE="3" COLOR="#FFFFCC" FACE="arial" >~miscellaneous</FONT> <A NAME="section_2"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>~follow-up~medication</div> <bR> <bR> <div> <B><IMG SRC="01e61e00.jpg" border=0 width="353" height="480" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> <B>Treatment to resume:</B></div> <bR> <div> This approach can be tried anywhere for nosebleed</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The person should sit up and lean forward so as not to swallow the blood. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The nose should be pinched over the bleeding site for 10 minutes by the clock. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If bleeding continues while pressure is applied, the nose is being held in the wrong spot and pressure should be applied in the correct spot for the full 10 minutes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The above method should be applied twice before seeking further medical treatment. </div> <div> Medical treatment.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The clots should be cleared by suction or blowing the nose. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">After visualising the bleeding site. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A wad with 0.25% phenylephrine nose drops is applied. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A wad with 1% lignocaine with 1:1000 epinephrine is applied. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A wad with 1% cocaine is inserted. (Cocaine is the most potent topical vasoconstrictor) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The insertion of a small piece of gelatin sponge (Gelfoam) or topical thrombin over the bleeding site can be tried. </div> <div> <B>Prevention</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Daily application of antibiotic ointment by cotton bud until five days have passed without a nosebleed and then weekly for one month. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In dry climates, humidification of the air may be of use. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avoid aspirin or other medications that trigger bleeding. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avoid vigorous nose blowing. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blood loss always looks greater than the actual amount lost. </div> <div> <B>Prognosis</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually correct home treatment reduces nosebleeds to an insignificant problem. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In the unusual situation where bleeding from the back of the nose occurs, referral to an Ear, Nose and Throat specialist is necessary. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f0ccffff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If severe and repeated bleeding occurs, then surgery may be needed. </div> <bR> </td> </tr></table></body>