Overview of Anterior Epistaxis Nasal Pack
Epistaxis, or nosebleeds, is one of the most common nose-related emergencies. It results in about 1.7 emergency room visits for every 1000 people every year. Usually, the type of nosebleed that happens at the front of the nose, known as anterior epistaxis, is often harmless and stops by itself or by applying direct pressure. These nosebleeds mostly affect children and the elderly. The reasons for it can be anything from picking the nose, putting something in the nose, to having fragile nasal tissues, or taking blood-thinning medication combined with high blood pressure.
In adults and middle-aged people, one of the common causes of nosebleeds is using drugs inside the nose. These can be medicinal like nose sprays with steroids, or recreational drugs like cocaine.
These kinds of nosebleeds tend to happen more in the winter. This is because the air from heating systems can dry out the inside of your nose, making it more likely to get irritated and bleed. If putting pressure on the nose for about 15 to 20 minutes doesn’t stop the bleeding, there are other methods that can help. Doctors can use medicines that make blood vessels narrow, or use a process called silver nitrate cautery. If none of these work, doctors might need to put a special packing in the nose to stop the bleeding.
Anatomy and Physiology of Anterior Epistaxis Nasal Pack
The Kiesselbach plexus, commonly involved in nosebleeds at the front of your nose, is found just inside the lower part of the nose. It’s a network of blood vessels that includes branches from several arteries, namely the anterior ethmoidal branch (from the ophthalmic artery), the sphenopalatine and greater palatine branches (from the maxillary artery), and the superior labial branch (from the facial artery). Some of these arteries come from the internal carotid system while others come from the external carotid system. These arteries help to supply blood to the nose and to the bone and cartilage underneath.
Most nosebleeds, or more than 90%, start at the front of the nasal septum. However, more serious bleeding can come from the back of the nose. If the nosebleed doesn’t stop with common treatments, it’s typically diagnosed as coming from the back of the nose, which may require longer nose packs and more observation after the procedure. Back of the nose (posterior) nosebleeds mostly come from end branches of the internal maxillary artery. Posterior nosebleeds could also come from the Woodruff plexus, a network of veins on the back side-wall of the nasal cavity.
Sometimes, nosebleeds aren’t just because of an injury but are a symptom of a health issue, such as a problem with blood clotting or platelets. It’s important to find and fix these health issues to make treatments more effective. People could bleed for various reasons without injury, including high blood pressure, low platelets, hemophilia, and use of aspirin, chemotherapy, or herbal supplements like turmeric. Managing blood pressure and giving fresh frozen plasma or platelets can make a big difference in whether nasal packing is successful. Some cases might need other treatments like giving vitamin K for an overdose of the drug warfarin, or desmopressin in von Willebrand disease, a bleeding disorder.
Why do People Need Anterior Epistaxis Nasal Pack
If you have a nosebleed that won’t stop even after pressure is applied, medications are used to constrict the blood vessels, or a medical procedure to stop the bleeding (cautery) is performed, then a doctor in the emergency room might use a special procedure called nasal packing. This involves placing materials inside your nose to help stop the bleeding. This method could also be used during or after surgery to help control any bleeding.
When a Person Should Avoid Anterior Epistaxis Nasal Pack
When a person goes to the emergency room with a nosebleed (medically termed anterior epistaxis), doctors often use a procedure called nasal packing to stop the bleeding. However, there are some cases where they cannot do this procedure:
If a person has a severe skull or face fracture, especially at the base of the skull or the nasal bone, the doctors might not do nasal packing. Also, if the person has unstable vital signs, like having fluctuating blood pressure, or needs an emergency blood transfusion, nasal packing might not be possible.
In the same way, if a person is facing breathing difficulties that require a procedure called intubation (inserting a tube in the person’s windpipe), they might not undergo nasal packing. Still, it is important to know that once these conditions are stabilized, the doctors might perform nasal packing to control a nosebleed.
Equipment used for Anterior Epistaxis Nasal Pack
If your doctor needs to perform an anterior nasal packing procedure, which is a treatment often used to control nosebleeds, they’ll use a variety of tools and materials. This procedure requires a few specific things, including:
* A hospital bed that can adjust so your back is at a 90-degree angle.
* A headlamp to help your doctor see clearly.
* An otoscope, a tool used to look inside your ears.
* A suction canister which can either be attached to the wall or portable.
* Different suction tips, called Frazier and either Yankauer or Goodhill, to help remove any fluid or blood.
* A nasal speculum which is a tool used to widen your nostrils for clear viewing.
* Bayonet forceps, a tool designed to hold and move tissues or other items.
* A tongue depressor to hold your tongue down if needed.
* Small pieces of gauze, both 4 inches by 4 inches and 2 inches by 2 inches.
* A dental roll is used to control bleeding and absorb fluids.
* Sterile lubricant to help reduce irritation from any tools.
* Antibiotic ointment to prevent infections.
* An intranasal vasoconstrictor, a medication that narrows the blood vessels in your nose to help control bleeding.
* Tranexamic acid, a medication that helps your blood clot.
* A topical anesthetic to numb your nose and make the procedure more comfortable.
* A nasal tampon or intranasal packing device, which is inserted into your nostril to control bleeding.
* Personal protective equipment, such as goggles, a face mask, gown, and gloves to ensure the procedure is safe and hygienic for both you and the doctor.
Who is needed to perform Anterior Epistaxis Nasal Pack?
A doctor or a highly trained healthcare worker can put a special kind of dressing called “anterior nasal packing” in your nose during an urgent or emergency situation. When conditions are severe, even a nurse or an emergency healthcare worker might do this procedure. This is done to protect the nose and stop heavy bleeding.
Preparing for Anterior Epistaxis Nasal Pack
If someone is bleeding from their nose, there are a few steps that can be taken to stop it. First, the patient should be stable and able to breathe freely. After this, doctors can use specific medicines to help tighten and narrow the blood vessels, slowing down the bleeding. These could include cocaine (4%), lidocaine (1-4%) mixed with a little bit of epinephrine, or oxymetazoline (0.05%).
After using one of these medicines, the patient should try squeezing the soft portion of their nose closed for about 15 to 20 minutes. This puts pressure on the bleeding area and can help stop the bleeding. Another option is the use of a nasal clip on the same area.
If these initial steps don’t stop the bleeding, the patient will need to sit straight up and lean their head forward a bit, sort of like they’re sniffing something. This allows doctors to have a better look inside the nose. They might need to use a small tool called a nasal speculum for a closer look and remove any big blood clots blocking the view. They could then use silver nitrate to try and cauterize, or burn, the specific area that’s bleeding. However, this might not work if the bleeding is pretty heavy. Another option is to use a special tool that uses electricity to stop the bleeding, if the area is easy to reach and the first method did not work.
If none of these treatments work, the next step is to pack the nose with special material to try and stop the bleeding. This last option is generally considered if other methods don’t successfully control the nosebleed.
How is Anterior Epistaxis Nasal Pack performed
Historically, to stop a nosebleed, doctors used to pack the affected nostril with a six-foot length of a petroleum-based gauze. This fills the side of the nostril to plug the bleeding. Today, this method is no longer commonly used and has been replaced by ready-made nasal packing devices. Nasal packing devices are simply tools used by doctors to put pressure on the inside of your nose in order to stop the bleeding.
Some of these tools are made from a substance called polyvinyl alcohol. They look like tampons with strings at the base and come in multiple sizes, for adults and children alike. When these devices touch moisture, they expand and directly touch the inside of your nose, putting pressure on the spot that is bleeding. If your nasal cavity is large, doctors may need to use multiple ones at the same time.
Another tool is an inflatable balloon. This balloon is covered with a substance called carboxymethyl cellulose. This not only puts pressure on the bleeding site but also helps your blood to clot faster.
While doctors are treating you, they avoid using sedatives and general anesthesia because it might interfere with the natural functioning of your airways.
The procedure for packing your nose with either type of nasal pack is almost identical. After your doctor makes sure you can breathe normally and has numbed your nose with a medication that narrows your blood vessels, they can start the process.
If using the tampon-like device, it might need to be soaked in water for 30 seconds before, depending on the brand. Once soaked, it’s then covered with an antibiotic ointment or petroleum jelly. The device is then slid into your nostril using firm, steady pressure, making sure to keep it parallel to the ground. Once inside, the device will start soaking up moisture and expand, putting pressure on the sores and stopping the bleeding.
For the inflatable balloon device, it is also coated with an antibiotic ointment or petroleum jelly. The deflated balloon is then slid into your nostril. Once in place, your doctor follows the manufacturer’s instructions to properly inflate it, typically with about 20 mL of air.
Your doctor then monitors you for a while to ensure that the bleeding has stopped. If there’s still bleeding after about half an hour to an hour, your doctor may have to resort to other treatments.
If you’re sent home after successful treatment, you’ll be scheduled to see an ear, nose and throat specialist within 24 to 48 hours for a checkup. Sometimes the doctor will prescribe oral antibiotics as a preventative measure, although this isn’t standard practice. The nasal packs normally stay in place for at least 24 hours. If they’re removed too soon, the risk of recurrent bleeding increases.
For patients with blood clotting issues, the procedure can be more challenging. Even delaying removal of the nasal pack for 72 hours can increase the risk of recurrent bleeding. This is why it is extremely important to manage any concurrent bleeding disorders at the time of pack placement. Its only in rare cases where help is required from a specialist in ear, nose, and throat or from interventional radiology for further management.
Patients with such clotting issues may need some additional steps to stop the bleeding. Some doctors may use materials that are absorbed over time, such as cellulose mesh, hemostatic matrix, or sinusotomy absorbable nasal packing. While they may not provide pressure as effectively as inflatable tampons or balloons, they carry less risk of injuring the inner lining of the nose and don’t require removal so they can’t cause damage upon removal.
Possible Complications of Anterior Epistaxis Nasal Pack
Anterior nasal packing, a method to control nose bleeds, can sometimes lead to issues. The most common ones include feeling pain when the pack is put in or removed, bleeding again when the pack is taken out, and not being able to properly stop the bleeding. In rare cases, blood may flow back through the tear duct, which can cause distress but is not really a complication.
Other problems, although rarer, include damage to the inside of the nose due to pressure or rubbing from the pack, infections such as sinusitis (inflammation of the sinuses) or toxic shock syndrome (a severe bacterial infection), the pack moving around, or even accidentally inhaling the pack.
Posterior nasal packing, another method to stop nosebleeds that involves packing the back of the nose, can have its own set of problems. It can make it hard for the patient to breathe, and sometimes it can cause a slowing heart rate or difficulty in breathing due to increased pressure at the back of the nose. This is why patients often need to be constantly monitored for any changes in their vital signs. Additionally, putting too much pressure to the back of the nose can risk damage to the soft roof of the mouth, so regular check-ups are important to avoid this.
What Else Should I Know About Anterior Epistaxis Nasal Pack?
Bleeding from the front part of the nose, also known as anterior epistaxis, is usually a temporary issue that resolves by itself. However, it can scare both the person experiencing it and those caring for them, often causing a lot of worry and stress. This is why emergency doctors need to be skilled at quickly and effectively stopping the nosebleed by using a method called nasal packing. Knowing what equipment is available in their hospital or clinic is also crucial because small differences between various tools and materials can impact how they are used.