Nasal packing là gì

Background

Epistaxis is a common problem in the emergency department (ED). Generally, it is relatively benign, but it can sometimes produce serious, life-threatening situations. Up khổng lồ 60% of the population is estimated to have sầu had at least 1 episode of epistaxis at some point in their lives. Of this group, 6% seek medical care lớn treat epistaxis, with 1.6 in 10,000 requiring hospitalization. <1>


Most cases of epistaxis occur in children younger than 10 years. Epistaxis is more comtháng in colder seasons và in northern climates because of decreased humidity và the consequent drying of the nasal mucosa. <2> Other major etiologies include inhaled medications, mucosal breakdown caused by infiltration by malignancy or granulomatous disease, & nasal trauma.

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Ninety percent of epistaxes are anterior, originating from the Kiesselbach plexus (see the image below). Anterior epistaxes exhibit unilateral, steady, nonmassive sầu bleeding. Just 10% of epistaxes are posterior, exhibiting massive bleeding that is initially bilateral.


Nasal vascular anatomy


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Nasal vascular anatomy.
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The lateral nasal wall is supplied by the sphenopalatine artery posteroinferiorly & by the anterior & posterior ethmoid arteries superiorly. The nasal septum also derives its blood supply from the sphenopalatine và the anterior và posterior ethmoid arteries with the added contribution of the superior labial artery (anteriorly) and the greater palatine artery (posteriorly). The Kiesselbach plexus, or the Little area, represents a region in the anteroinferior third of the nasal septum, where all 3 of the chief blood supplies to the internal nose converge. For more information about the relevant anatomy, see Nasal Anatomy.

A focused history sida the clinician in managing the acutely bleeding patient. This history should include some or all of the following questions:


Which side is bleeding?


Which side was bleeding initially?


What is the estimated amount of blood loss?


Is it recurrent?


Is it in the pharynx?


Has any trauma recently occurred?


Are symptoms of hypovolemia present?


As with any unstable patient, initial management begins by assessing airway, breathing, và circulation (the ABCs). Next, the source of the bleeding should be identified. The source of most anterior bleeds can be identified using a headlight and adequate suction.

Once the bleeding point is identified, cauterization—either chemical (silver nitrate) or electrical (hotwire or bipolar cautery)—usually provides definitive sầu treatment. <4> If cauterization is unsuccessful, anterior nasal packing is the next step.

Nasal packing is the placement of an intranasal device that applies constant local pressure to lớn the nasal septum. Nasal packing works by (1) direct pressure; (2) consequent reduction of mucosal irritation, which decreases bleeding; and (3) clot formation surrounding the foreign toàn thân, which enhances pressure.

For more information, see Epistaxis, Management of Axinh tươi Epistaxis, & Posterior Epistaxis Nasal Pack.


Indications

Anterior nasal packing is indicated for overt or suspected epistaxis after direct pressure, topical agents, or silver nitrate cauterization. It may be indicated in hematemesis or melena (either of which can be a presentation of posterior epistaxis).


Contraindications

Patients with respiratory compromise may first require airway control & mechanical ventilation. Patients with hemodynamic compromise may first require volume và blood hàng hóa resuscitation.



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Technique


Overview

Airway, breathing, and circulation (ABCs) take priority in the adễ thương management of epistaxis. Less invasive approaches lớn controlling epistaxis should be attempted before anterior nasal packing is initiated. <5, 6, 7>


Go khổng lồ Surgery for Pediatric Epistaxis for complete information on this topic.


Direct Pressure

Apply anterior nasal pressure to the cartilaginous part of the nose for trăng tròn minutes (see the image below). If this maneuver does not control the bleeding, a more invasive sầu approach is required.


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Anterior nasal pressure with joined tongue depressors.
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Assemble equipment & put on gown, goggles, & gloves. A headlamp, if available, is helpful; its use enhances the visual field. Keep patient in an upright or minimally reclined position.


Topical Anesthesia and Vasoconstriction

Soak cốt tông balls in a phối of 2% lidocaine và 1:1000 epinephrine. Put 1-2 cốt tông balls into the bleeding nostril. (If bleeding is not clearly unilateral, put cốt tông balls into both nostrils.) Place a dry cốt tông ball at the external nares lớn prsự kiện leakage và dripping. Leave sầu the cotton balls in place for 10 minutes.


If these anesthetic supplies are unavailable, a commercially produced topical nasal decongestant may be quickly inhaled; then, place cotton balls & apply anterior nasal pressure.


Evacuation of Blood và Clot

Remove the cotton balls placed for local anesthesia. To evacuate clots, use suction or have sầu patient blow gently. Previously accumulated blood comes out in a gush and then stops. Ongoing bleeding appears as steadily dripping, bright red blood.

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Identification of Bleeding Source

Stabilize your h& on the patient’s face, and visualize the septum through the nasal speculum. Examine the Kiesselbach plexus for bleeders. If the offending vessel has stopped bleeding, it will appear as a red dot on the mucosa that may have sầu a small amount of clot on it. If the vessel is still bleeding, active sầu oozing will be visible.


Cauterization of Bleeding Source

A clear view of the bleeding source is mandatory for the use of cauterization methods. Cauterize to cease unilateral septal bleeding only. Bilateral cauterization, whether chemical or electrical, increases the risk of septal perforation.


For chemical cauterization, apply a silver nitrate stiông xã khổng lồ the red dot or oozing vessel for 5-10 seconds, then roll it over the surrounding area (1 cm) for 5-10 seconds to lớn cauterize feeding vessels. Apply antibiotic ointment over cauterized area. This provides prophylaxis against infection and serves as a topical barrier to lớn prevent desiccation and restart of bleeding.


Patient with a history of significant left-sided epistaxis. Packing was performed in the emergency department with continued bleeding. After packing removal, small vessel arterial bleeding was noted on the anterior septum. Silver nitrate cautery is applied & dressed with dissolvable microfibrillar collaren. Video courtesy of Vijay Ramakrishnan, MD.
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Electrical cauterization is typically used by an otolaryngologist in the context of endoscopic visualization.


Nasal Packing

Anterior nasal packing is required when external pressure và cauterization fail to lớn control anterior bleeding, though some clinicians elect lớn use anterior nasal packing as their first-line approach. The goal is lớn place an intranasal device that applies constant local pressure khổng lồ the nasal septum. Traditional gauze packing is sufficient if prefabricated nasal tampons lượt thích Rapid Rhino or Merocel are not available (see Equipment).


A prospective study of 42 patients was performed khổng lồ compare the efficacy & patient tolerance of Merocel and Rapid Rhino nasal tampons. No significant difference in efficacy or patient comfort was revealed between the 2 types of packs. Rapid Rhino produced significantly lower scores for subjective patient discomfort during insertion & removal of paông xã. <8>


Packing with commercial products


Anterior packing with prefabricated nasal tampons begins with applying anesthetic to the nasal mucosa with cốt tông balls or via inhalation. Apply surgical lubricant to the tampon, and gently insert it khổng lồ the maximum achievable depth. Advance the tampon almost horizontally, along the floor of the nasal cavity.


The Merocel nasal tampon is made of polyvinyl alcohol, which is a compressed foam polymer that is inserted inkhổng lồ the nose & expanded by application of water. The nasal tampon swells and fills the nasal cavity và applies pressure over the bleeding point. The Merocel tampon is believed to lớn aggregate clotting factors to lớn reach a critical level, thereby promoting coagulation. The Merocel success rate is 85% (equal to lớn that of traditional ribbon gauze).


The Rapid Rhino anterior balloon tampon is made of carboxymethylcelluthua kém, a hydrocolloid material. It acts as a platelet aggregator and also forms a lubricant upon contact with water. Unlượt thích Merocel, the Rapid Rhino balloon has a cuff that is inflated by air. The hydrocolloid or Gel-Knit reportedly preserves the newly-formed clot during tampon removal.


Packing with gauze


Anterior packing with gauze begins similarly, with the application of anesthetic to the nasal mucosa with cotton balls or via inhalation. Prepare a length of ribbon gauze impregnated with petrolatum jelly. Use bayonet forceps và a nasal speculum to place the gauze in a layered, accordion fashion, packing it from anterior to lớn posterior (see the image below). The gauze should be placed as far posteriorly as is possible.


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Nasal packing with bayonet forceps & ribbon gauze.
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Failure of anterior nasal packing


If anterior packing failed to lớn stop a confirmed & visualized anterior bleeding source, consider bilateral packing to increase the pressure on the nasal septum. If the anterior bleeding source was unconfirmed and bleeding continues, suspect posterior bleeding.


For a detailed description of posterior nasal packing, see Posterior Epistaxis Nasal Paông xã.



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Preparation


Anesthesia

Topical anesthetics include a 2% (or 4%) solution of lidocaine (see the image below).


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Lidocaine 2%.
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Topical nasal vasoconstrictors include the following:


Phenylephrine (Neo-Synephrine Fast-Acting Nasal)


Oxymetazoline (Afrin, Neo-Synephrine 12-hour Maximum Strength Nasal)


Epinephrine


Mixture of anesthetics and vasoconstrictors include the following:


Phenylephrine plus lidocaine


Epinephrine (0.25 mL of 1:1000 solution ) plus lidocaine (trăng tròn mL 2% )


Equipment

Equipment includes the following:


Gloves


Eye shield


Procedure lighting (best to use a headlamp)


Tape


Cotton


Tongue depressors


Commercially produced nasal tampon - Gelfoam (absorbable gelatin), Surgicel (oxidized cellulose), Merocel nasal tampon (see the first và second images below)


Rapid Rhino anterior balloon tampon (see the third image below)


Topical vasoconstrictors và anesthetics


Nasal speculum (see the fourth image below)


Suction apparatus (Frazier suction tip) (see the fifth image below)


Silver nitrate cautery sticks (see the sixth image below)


Positioning

Place the patient in an upright, not a recumbent, position (see the images below) unless hemodynamic instability prevents this positioning.


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Patient sitting in an inappropriate, reclined position.
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Patient sitting in an appropriate, upright position.
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Post-Procedure


Postoperative sầu Care

All patients treated with nasal packing should receive an antistaphylococcal antibiotic as prophylaxis against sinusitis & staphylococcal toxic shoông xã syndrome. Patients who were cauterized only (& did not receive sầu nasal packing) should gently apply antibiotic ointment to the cauterized area daily for 1 week and use a humidifier while sleeping.

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Patients should be given a follow-up appointment for removal of the packing in 48 hours. Instruct the patient khổng lồ maintain upright posture for 48 hours (including sleep hours) và khổng lồ avoid laughter or heavy lifting for 24 hours. The goal is the reduction of intracranial venous blood pressure to lớn minimize the likelihood of rebleeding.


Complications

Complications of epistaxis and treatment include the following:


Hemorrhagic shock


Septic shock


Pneumocephalus


Septal pressure necrosis


Neurogenic syncope during packing


Epiphora (from blockage of the lacrimal duct)


Hypoxia (from impaired nasal air movement)


Staphylococcal toxic shochồng syndrome


If bleeding cannot be controlled, otolaryngologic consultation is necessary. Advanced hemostatic measures may also be necessary, as follows:


Arterial ligation (internal maxillary, sphenopalatine)


Nasal septal dermoplasty


tia laze ablation



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Questions và Answers


Overview

What is epistaxis?

What is the nasal vascular anatomy relevant khổng lồ epistaxis?

What is the focus of clinical history for evaluation of anterior nasal epistaxis?

What is the clinical presentation of anterior nasal packing for epistaxis?

When is anterior nasal packing indicated for epistaxis?

When is anterior nasal packing contraindicated for epistaxis?

How is epistaxis treated prior to anterior nasal packing?

What is the role of direct pressure in anterior nasal packing for epistaxis?

What is the role of anesthesia in anterior nasal packing for epistaxis?

What is the role of evacuation of blood in anterior nasal packing for epistaxis?

How is the bleeding source identified in anterior nasal packing for epistaxis?

How is cauterization of the bleeding source performed in anterior nasal packing for epistaxis?

When is anterior nasal packing for epistaxis performed?

When is the efficacy of anterior nasal packing for epistaxis?

What is the role of commercial products in anterior nasal packing for epistaxis?

How is the anterior nasal packing for epistaxis performed?

What should be considered if anterior nasal packing for epistaxis fails?

Which medical equipment is need to perkhung anterior nasal packing for epistaxis?

Which anesthetics are used in anterior nasal packing for epistaxis?

How is the patient positioned for anterior nasal packing for epistaxis?

What are the possible complications of epistaxis?

What is included in post-procedure care following anterior nasal packing for epistaxis?


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