ear, nose, and throat disorders
How To Treat Anterior Epistaxis With Nasal Packing
Step by Step Description of Treating Anterior Epistaxis With Packing
Initial steps Have the patient gently blow the nose to remove clots, or suction the nasal passageway carefully. Insert a nasal speculum with your index finger resting against the patient's nose or cheek and the handle parallel to the floor (so the blades open vertically). Slowly open the speculum and examine the nose using a bright headlamp or head mirror, which leaves one hand free to manipulate suction or an instrument. Use a Frazier-tip suction catheter to remove any blood and clots obscuring the view. Look for blood flowing from the anterior septum in the area of Kiesselbach's plexus, and look for blood flowing from the back of the nose. Apply a topical vasoconstrictor/anesthetic mixture: Place about 3 mL of 4%cocainesolution or 4%lidocainewithoxymetazolinein a small medicine cup and soak 2 or 3 cotton pledgets with the solution and insert them into the nose, stacked vertically (or spray in a topical vasoconstrictor such asoxymetazolineand place pledgets containing only topical anesthetic). Leave the topical drugs in place for 10 to 15 minutes to stop or reduce the bleeding, provide anesthesia, and reduce mucosal swelling. To insert resorbable packing Gelatinthrombinhemostatic matrix and carboxymethylcellulose foam require reconstitution prior to use as outlined in the manufacturer's instructions. Attach the applicator syringe to the provided nasal catheter. Gently guide the catheter into the nasal cavity along the nasal floor, and then angle the catheter slightly upward. As the syringe is withdrawn, apply gentle pressure to the syringe to fill the nasal cavity with the hemostatic material. Oxidized regenerated cellulose is supplied as a powder or as a fabric. The powder formulation is ideal for epistaxis control because it covers broad surfaces and does not require precise placement. The powder is provided in a syringe-like delivery device with an attached catheter. Place the catheter into the nasal cavity. Pump the delivery device as needed to coat the nasal cavity with the hemostatic powder. Synthetic polyurethane and chitosan-containing polymers are provided as resorbable sponges. Insertion is similar to the placement of nonresorbable sponges. Place the sponge perpendicular to the face and advance it parallel to the nasal floor in a single, smooth movement. The sponge should not be coated in any medication or substance prior to insertion. The sponge expands automatically with the absorption of blood. Always observe the patient for at least 10 minutes after placement of resorbable packing to ensure that bleeding has been controlled. To insert a nonresorbable compressed (expandable) nasal sponge Coat the sponge with a topical antibiotic ointment, such asbacitracinormupirocin. The ointment also lubricates the sponge to facilitate insertion. Trim the length and width of the sponge to fit the nose. A typical 8-cm commercial nasal sponge can fit into an adult nasal cavity without modification. Insert the sponge perpendicular to the face and advance it parallel to the floor of the nasal cavity in a single, smooth movement to limit discomfort. After the sponge has been properly inserted, expand the sponge by injecting 5 to 10 mL of saline or local anesthetic onto the sponge using an 18- to 22-gauge angiocatheter. Tie the drawstring (if present) around a piece of gauze to prevent displacement posteriorly, or tape the string to the cheek. If necessary, insert a second sponge to fill the nasal cavity. Be sure that the tips of both sponges are at the level of the nares or protrude slightly. Observe the patient for 10 minutes after sponge insertion to ascertain control of bleeding. To insert an inflatable balloon device If the balloon has a carboxymethylcellulose outer fabric, soak the device in sterile water for up to 30 seconds (do not soak in saline). Follow the manufacturer's instructions. Insert the device perpendicular to the face and advance it parallel to the floor of the nasal cavity until the plastic ring is within the nasal cavity. Inflate the device with air using a 20-mL syringe until the pilot cuff becomes rounded and firm. Do not inflate with water or saline and do not apply lubricants or antibiotic ointments to the device. Secure the inflation port to the patient's face using tape or a transparent dressing. To insert petrolatum gauze packing For patients who appear unlikely to tolerate the procedure, consider giving a low dose of IV analgesic (eg, 0.5 to 1.0 mcg/kgfentanylto a maximum dose of 100 mcg and potentially lower in those > 65 years old). Grasp the petrolatum gauze with bayonet forceps about 10 cm from the end (this determines how deeply the gauze will be placed). Advance the strip of petrolatum gauze posteriorly into the nasal cavity parallel to the nasal floor until the end of the gauze strip is just outside the opening of the naris. Grasp another 8 to 10 cm of strip gauze and place this on top of the prior layer in an accordion fashion, being sure that it is inserted parallel to the nasal floor and extends the full length of the nasal cavity. Be sure to grasp a long enough piece each time to allow insertion to the back of the nose in a single motion. Place each layer slightly anterior to the previous layer to prevent the packing from slipping posteriorly. Press down on the packing with the bayonet forceps to pack it tighter after placement of every several layers. Continue to add layers of strip gauze until the nasal cavity is packed. The full length of strip gauze—typically, 180 cm (72 inches)—may be required. 