医药卫生鼻出血课件

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 historyHippocrates 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,TSSNugauze 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 Cauteryabout 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 bipol