鼻出血(英文).ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,EPISTAXIS,Glen Porter,MD,Francis B.Quinn,MD,UTMB-Galveston,Galveston,Texas,Introduction and History,5-10%of the population experience an episode of,epistaxis,each year.10%of those will see a physician.1%of those seeking medical care will need a specialist.,Mythology:brown paper,nails,scissors,scarlet threads,“lead that has never touched the ground”,A condition with a long history,Hippocrates,to Henry Goodyear.,Anatomy/Physiology of Epistaxis,Anatomy,Nasal cavity,Vascular supply,Physiology,Vascular nature,Mucosa,Why bleeding from the nose?,Vascular organ secondary to incredible heating/humidification requirements,Vasculature runs just under mucosa(not squamous),Arterial to venous,anastamoses,ICA and ECA blood flow,Anatomy of the Lateral Nasal Wall,SPF,-class I(35%),-class II(56%),-class III(9%),External Carotid Artery,-,Sphenopalatine,artery,-Greater palatine artery,-Ascending pharyngeal artery,-Posterior nasal artery,-Superior Labial artery,Internal Carotid Artery,-Anterior Ethmoid artery,-Posterior Ethmoid artery,Pterygopalatine,Vasculature,-Internal maxillary artery,Anatomy of the Nasal Cavity and Vasculature,Sphenopalatine,AA,Ethmoid AA,Greater Palatine A,Kesselbachs,Plexus/,Littles,Area:,-Anterior Ethmoid(,Opth,),-Superior Labial A(Facial),-,Sphenopalatine,A(IMAX),-Greater Palatine(IMAX,),Woodruffs Plexus:,-Pharyngeal&Post.Nasal AA of,Sphenopalatine,A(IMAX),Anterior vs.Posterior,Maxillary sinus,ostium,Anterior:younger,usually septal vs.anterior ethmoid,most common(90%),typically less severe,Posterior:older population,usually from Woodruffs plexus,more serious.,Etiology,Local factors,Vascular,Infectious/Inflammatory,Trauma(most common),Iatrogenic,Neoplasm,Dessication,Foreign Bodies/other,Etiology,Systemic factors,Vascular,Infection/Inflammation,Coagulopathy,Local Factors-Vascular,ICA Aneurysms,extradural,cavernous sinus,Local Factors-Infection/Inflammation,Rhinitis,/Sinusitis,Allergic,Bacterial,Fungal,Viral,Local Factors-Trauma,Nose picking,Nose blowing/sneezing,Nasal fracture,Nasogastric,/,nasotracheal,intubation,Trauma to sinuses,orbits,middle ear,base of skull,Barotrauma,Nasal Fracture with Septal Hematoma,Local Factors-,Iatrogenic,nasal injury,Functional endoscopic sinus surgery,Rhinoplasty,Nasal reconstruction,Local Factors-Neoplasm,Juvenile nasopharyngeal,angiofibroma,Inverted,papilloma,SCCA,Adenocarcinoma,Melanoma,Esthesioneuroblastoma,Lymphoma,Local Factors,Dessication,Cold,dry airmore common in wintertime,Dry heatPhoenix and Death valley,Nasal oxygen,Anatomic abnormalities,Atrophic,rhinitis,Local Factors-Other,Self-inflicted (,pedi,)vs.traumatic foreign bodies,Intranasal parasites,Septal perforation,Chemical(cocaine,nasal sprays,ammonia,etc.),Systemic Factors-Vascular,Hypertension/Arteriosclerosis,Hereditary Hemorrhagic,Telangectasias,(OWR),Systemic Factors Infection/Inflammation,Tuberculosis,Syphillis,Wegeners Granulomatosis,Periarteritis nodosa,SLE,Systemic Factors,Coagulopathies,Thrombocytopenia,Platelet dysfunction,Systemic disease(Uremia),drug-induced(,Coumadin,/,NSAIDs,/Herbal supplements),Clotting Factor Deficiencies,Hemophilia,VonWillebrands,disease,Hepatic failure,Hematologic,malignancies,Etiology and Age,Childrenforeign body,nose picking,nasal,diptheria,(1/3 with chronic bleeds have coagulation d/o),Adultstrauma,idiopathic,Middle agetumors,Old age-hypertension,Initial Management,ABCs,Medical history/Medications,Vital signsneed IV?,Physical exam,Anterior,rhinoscopy,Endoscopic rhinoscopy,Laboratory exam,Radiologic,studies,suction,good light,anesthetic,silver nitrate,merocels,gelfoam,bacitracin,endoscopes,suction,bovie,/bipolar,Afrin,T.C.A.,surgicel,epistat,bayonet,forcepts,vaseline,gauze,Non-surgical treatments,Control of hypertension,Correction of,coagulopathies,/,thrombocytopenia,FFP or whole blood/reversal of anticoagulant/platelets,Pressure/Expulsion of clots,Topical decongestants/,vasocontrictors,Cautery,(AgNo3 vs.TCA vs.Bipolar vs.,Bovie,),Nasal packing(effective 80-90%of time),Greater palatine foramen block,Non-surgical treatments on d/c,Humidity/,emolients,Discontinue offending meds,Nasal saline sprays,Avoidance of nose picking/blowing,Sneeze with mouth open,Avoid straining/,bedrest,Nasal packs,Anterior nasal packs,Traditional,Recent modifications,Posterior nasal packs,Traditional,Recent modifications,Ant/Post nasal packing,Pick a Pack,any pack,Pick a pack to pack with,TSS,Nugauze,vs.,Merocel,Electron microscopy,Posterior Packs Admission,Elderly and those with other chronic diseases may need to be admitted to the ICU,Continuous cardiopulmonary monitoring,Antibiotics,Oxygen supplementation may be needed,Mild sedation/analgesia,IVF,Indications for surgery/,embolization,Continued bleeding despite nasal packing,Pt requires transfusion/admit,hct,of 72hrs(,wang,vs.,schaitkin,),Selective,Angiography,/,embolization,Helps identify location of bleeding,Embolization,most effective in patients who,Still bleeding after surgical arterial ligation,Bleeding site difficult to reach surgically,Comorbidities,prohibit general anesthetic,Effective only when bleeding is.5 ml/min,90+%success rate,complication rate of 0.1%,Only able to,embolize,external carotid&branches,Complications:minor(18-45%)/major(0-2%),Contraindicated in bad,atherosclerosis,Ethmoid bleed,Surgical treatment,Transmaxillary,IMA ligation,Intraoral IMA ligation,Anterior/Posterior,Ethmoidal,ligation,Transnasal Sphenopalatine,ligation,External carotid artery ligation,Septodermoplasty,/Laser ablation,Transmaxillary,IMA ligation,Waters view,Caldwell-Luc,Electrocautery,of posterior wall before removal,Microscopic dissection and ligation of IMA-descending palatine&,sphenopalantine,most important,Recurrence rate(failure rate)of 10-15%,Complication rate of 25-30%(,oa,fistula,dental,n),Intraoral IMA ligation,Posterior,gingivobuccal,incision beginning at second molar,Temporalis mm split and partially dissected,IMAX visualized,clipped and divided,Advantages:children/facial fractures,Disadvantages:more proximal ligation,Complications:trismus,damage to,infraorbital,n,Ant./Post.,Ethmoidal,ligation,Patients s/p IMAX ligation still bleeding,superior nasal cavity,epistaxis,or in conjunction when source unclear,Lynch incision,Fronto,-ethmoid,suture line,12-24-6,(14-18,8-10,4-6),Transnasal Endoscopic Sphenopalatine,Artery ligation,Follow Middle Turbinate to,posteriormost,aspect,Vertical,mucoperiosteal,incision 7-8mm anterior to post middle,turb,(between mid.and inf.,turbs,),Elevation of flapID neurovascular bundle at foramen,Ligation with titanium clip,Reapproximate flap,Complications few,Failures0-13%,Transnasal Spheno,-palatine Artery ligation,ECA ligation,Effectiveness,Anterior border of SCM,ID ECA/ICA,Ligation after clear that surrounding structures are safe.,Septodermoplasty,/Laser,Remove mucosa from anterior septum,floor of nose,lateral wall,STSG vs.cutaneous,myocutaneous,microvascular free flaps vs.,Autografts,Neodymium-yttrium-garnet(,Nd,-YAG)laser or Argon laser+topical steroid best,nonsurg,rx for mild/mod disease,Still bleed,but not as bad,Definitive treatment(severe disease)closure of nose,Statistically speaking,.,Some authors(Wang and Vogel)showed surgical intervention to have lower failure rates(14.3 vs.26.2),decreased complications(40 vs.68),and shorter hospital stays(2.2 less)than those w/posterior packs.,Others compared all medical treatment to surgery and showed cost cut using medical management.,Complication rates:posterior packs-25-40%,embolization,27%,IMAX ligation 28%,Cost analysis:IMAX vs.,Embolization,vs.Surgical,Cautery,about equal,Failure rates:PP-30%,Sx,-17%,Emb,-4%,Tips and Pearls,Red rubber on suction in contralateral nasal cavity,AgNO3 x 30seconds or more(not on both sides of septum),Antihistamines to prevent,rebleeds,Cautery,does not work with no platelets/clotting,Glove packing,H2O2,Merocels,(2 or more)injected with,cortisporin,otic,Amicar,spray,Tips and Pearls,Hot water irrigation,Cold water irrigation,Salt Pork,Dont pack nose in unconscious person with suspected skull fractures.,Antibiotic cream vs.silver nitrate,Intranasal pressure,Estrogen cream to nasal septum,Tips and Pearls,Transnasal endoscopic,bipolar,cautery,of,sphenopalatine,artery(7%failure in pts with obvious source of bleed),Submucosal supraperichondrial,dissection of nasal septum,Not all hospitals have,embolization,-trained,interventionalists,No hard-set outline.Do what is best for your particular patient,CASE REPORT,45,yo,Vietnamese fisherman-stable,but uncomfortable,Profuse nasal bleeding since 0200 this a.m.,History:No known medical problems.Drinks 6-12 beers/day.Takes no medications.No history of easy bleeding.No family history.,Physical exam:Profuse bleeding from both nostrils LR and bleeding down the back of his throatcoughing up clots.Unable to locate precise location of bleedappears to be posterior/superior.,Case 1 contd,Hgb,12.5,Lactated Ringers IVF bolus,Nasal packs removed two days later in the clinic,rebleeds,.,Requires transfusion for,Hgb,of 6.5,Angiography,no obvious bleed/,Embolization,Ant/Post Ethmoid Artery ligation,