鼻出血英文版培训课件

鼻出血英文版IntroductionandHistory 5-10%ofthepopulationexperienceanepisodeofepistaxiseachyear.10%ofthosewillseeaphysician.1%ofthoseseekingmedicalcarewillneedaspecialist.Mythology:brownpaper,nails,scissors,scarletthreads,“leadthathasnevertouchedtheground”Aconditionwithalonghistory—HippocratestoHenryGoodyear.2鼻出血英文版Anatomy/PhysiologyofEpistaxisAnatomyNasalcavityVascularsupplyPhysiologyVascularnatureMucosa3鼻出血英文版Whybleedingfromthenose?Vascularorgansecondarytoincredibleheating/humidificationrequirementsVasculaturerunsjustundermucosa(notsquamous)ArterialtovenousanastamosesICAandECAbloodflow4鼻出血英文版AnatomyoftheLateralNasalWallSPF-classI(35%)-classII(56%)-classIII(9%)5鼻出血英文版Sphenopalatineforamen(SPF)ClassClass1:theopeningoftheSPFispurelyintothesuperiormeatusClass2:theSPFspanstheethmoidalcrest(i.eopenstobothsuperiorandmiddlemeatiClass3:therearetwoseparateopeningintothesuperiorandmiddlemeati6鼻出血英文版ExternalCarotidArtery -Sphenopalatineartery -Greaterpalatineartery -Ascendingpharyngealartery -Posteriornasalartery -SuperiorLabialarteryInternalCarotidArtery -AnteriorEthmoidartery -PosteriorEthmoidartery7鼻出血英文版PterygopalatineVasculature--Internalmaxillaryartery8鼻出血英文版AnatomyoftheNasalCavityandVasculature9鼻出血英文版SphenopalatineAAEthmoidAAGreaterPalatineA10鼻出血英文版11鼻出血英文版12鼻出血英文版Kesselbach’sPlexus/Little’sArea:-AnteriorEthmoid(Opth)-SuperiorLabialA(Facial)-SphenopalatineA(IMAX)-GreaterPalatine(IMAX)Woodruff’sPlexus:-Pharyngeal&Post.NasalAAofSphenopalatineA(IMAX)

13鼻出血英文版14鼻出血英文版Anteriorvs.PosteriorMaxillarysinusostiumAnterior:younger,usuallyseptalvs.anteriorethmoid,mostcommon(>90%),typicallylessseverePosterior:olderpopulation,usuallyfromWoodruff’splexus,moreserious.15鼻出血英文版EtiologyLocalfactorsVascularInfectious/InflammatoryTrauma(mostcommon)IatrogenicNeoplasmDessicationForeignBodies/other16鼻出血英文版EtiologySystemicfactorsVascularInfection/InflammationCoagulopathy17鼻出血英文版LocalFactors--VascularICAAneurysmsextraduralcavernoussinus18鼻出血英文版LocalFactors-Infection/InflammationRhinitis/SinusitisAllergicBacterialFungalViral19鼻出血英文版LocalFactors-TraumaNosepickingNoseblowing/sneezingNasalfractureNasogastric/nasotrachealintubationTraumatosinuses,orbits,middleear,baseofskullBarotrauma20鼻出血英文版NasalFracturewithSeptalHematoma21鼻出血英文版LocalFactors-IatrogenicnasalinjuryFunctionalendoscopicsinussurgeryRhinoplastyNasalreconstruction22鼻出血英文版LocalFactors-NeoplasmJuvenilenasopharyngealangiofibromaInvertedpapillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphoma23鼻出血英文版24鼻出血英文版LocalFactors–

DessicationCold,dryair—morecommoninwintertimeDryheat—PhoenixandDeathvalleyNasaloxygenAnatomicabnormalitiesAtrophicrhinitis25鼻出血英文版LocalFactors-OtherSelf-inflicted(pedi)vs.traumaticforeignbodiesIntranasalparasitesSeptalperforationChemical(cocaine,nasalsprays,ammonia,etc.)26鼻出血英文版SystemicFactors--VascularHypertension/ArteriosclerosisHereditaryHemorrhagicTelangectasias(OWR)27鼻出血英文版SystemicFactors– Infection/InflammationTuberculosisSyphillisWegener’sGranulomatosisPeriarteritisnodosaSLE28鼻出血英文版SystemicFactors–Coagulopathies

ThrombocytopeniaPlateletdysfunctionSystemicdisease(Uremia)drug-induced(Coumadin/NSAIDs/Herbalsupplements)ClottingFactorDeficienciesHemophiliaVonWillebrand’sdiseaseHepaticfailureHematologicmalignancies29鼻出血英文版EtiologyandAgeChildren—foreignbody,nosepicking,nasaldiptheria(1/3withchronicbleedshavecoagulationd/o)Adults—trauma,idiopathicMiddleage—tumorsOldage--hypertension30鼻出血英文版InitialManagementABC’sMedicalhistory/MedicationsVitalsigns—needIV?PhysicalexamAnteriorrhinoscopyEndoscopicrhinoscopyLaboratoryexamRadiologicstudies31鼻出血英文版suctiongoodlightanestheticsilvernitratemerocelsgelfoambacitracinendoscopessuctionbovie/bipolarAfrinT.C.A.surgicelepistatbayonetforceptsvaselinegauze32鼻出血英文版Non-surgicaltreatmentsControlofhypertensionCorrectionofcoagulopathies/thrombocytopeniaFFPorwholeblood/reversalofanticoagulant/plateletsPressure/ExpulsionofclotsTopicaldecongestants/vasocontrictorsCautery(AgNo3vs.TCAvs.Bipolarvs.Bovie)Nasalpacking(effective80-90%oftime)Greaterpalatineforamenblock33鼻出血英文版Non-surgicaltreatments–ond/cHumidity/emolientsDiscontinueoffendingmedsNasalsalinespraysAvoidanceofnosepicking/blowingSneezewithmouthopenAvoidstraining/bedrest34鼻出血英文版NasalpacksAnteriornasalpacksTraditionalRecentmodificationsPosteriornasalpacksTraditionalRecentmodificationsAnt/Postnasalpacking35鼻出血英文版PickaPack,anypack36鼻出血英文版Pickapacktopackwith37鼻出血英文版TSS—Nugauzevs.MerocelElectronmicroscopy38鼻出血英文版PosteriorPacks–AdmissionElderlyandthosewithotherchronicdiseasesmayneedtobeadmittedtotheICUContinuouscardiopulmonarymonitoringAntibioticsOxygensupplementationmaybeneededMildsedation/analgesiaIVF39鼻出血英文版Indicationsforsurgery/embolizationContinuedbleedingdespitenasalpackingPtrequirestransfusion/admithctof<38%(barlow)NasalanomalyprecludingpackingPatientrefusal/intoleranceofpackingPosteriorbleedvs.failedmedicalmgmtafter>72hrs(wangvs.schaitkin)40鼻出血英文版SelectiveAngiography/embolizationHelpsidentifylocationofbleedingEmbolizationmosteffectiveinpatientswhoStillbleedingaftersurgicalarterialligationBleedingsitedifficulttoreachsurgicallyComorbiditiesprohibitgeneralanestheticEffectiveonlywhenbleedingis>.5ml/min90+%successrate,complicationrateof0.1%Onlyabletoembolizeexternalcarotid&branchesComplications:minor(18-45%)/major(0-2%)Contraindicatedinbadatherosclerosis,Ethmoidbleed41鼻出血英文版SurgicaltreatmentTransmaxillaryIMAligationIntraoralIMAligationAnterior/PosteriorEthmoidalligationTransnasalSphenopalatineligationExternalcarotidarteryligationSeptodermoplasty/Laserablation42鼻出血英文版44鼻出血英文版IntraoralIMAligationPosteriorgingivobuccalincisionbeginningatsecondmolarTemporalismmsplitandpartiallydissectedIMAXvisualized,clippedanddividedAdvantages:children/facialfracturesDisadvantages:moreproximalligationComplications:trismus,damagetoinfraorbitaln45鼻出血英文版Ant./Post.EthmoidalligationPatientss/pIMAXligationstillbleeding,superiornasalcavityepistaxis,orinconjunctionwhensourceunclearLynchincisionFronto-ethmoidsutureline12-24-6(14-18,8-10,4-6)46鼻出血英文版TransnasalEndoscopicSphenopalatineArteryligationFollowMiddleTurbinatetoposteriormostaspectVerticalmucoperiostealincision7-8mmanteriortopostmiddleturb(betweenmid.andinf.turbs)Elevationofflap—IDneurovascularbundleatforamenLigationwithtitaniumclipReapproximateflapComplications–few,Failures—0-13%47鼻出血英文版TransnasalSpheno-palatineArteryligation48鼻出血英文版ECAligation EffectivenessAnteriorborderofSCMIDECA/ICALigationafterclearthatsurroundingstructuresaresafe.49鼻出血英文版Septodermoplasty/LaserRemovemucosafromanterior½septum,floorofnose,lateralwallSTSGvs.cutaneous,myocutaneous,microvascularfreeflapsvs.AutograftsNeodymium-yttrium-garnet(Nd-YAG)laserorArgonlaser+topicalsteroidbestnonsurgrxformild/moddiseaseStillbleed,butnotasbadDefinitivetreatment(severedisease)—closureofnose50鼻出血英文版Statisticallyspeaking,….Someauthors(WangandVogel)showedsurgicalinterventiontohavelowerfailurerates(14.3vs.26.2),decreasedcomplications(40vs.68),andshorterhospitalstays(2.2less)thanthosew/posteriorpacks.Otherscomparedallmedicaltreatmenttosurgeryandshowedcostcutusingmedicalmanagement.Complicationrates:posteriorpacks-25-40%,embolization27%,IMAXligation28%Costanalysis:IMAXvs.Embolizationvs.SurgicalCautery—aboutequalFailurerates:PP-30%,Sx-17%,Emb-4%51鼻出血英文版TipsandPearlsRedrubberonsuctionincontralateralnasalcavityAgNO3x30secondsormore(notonbothsidesofsep