《鼻出血英》PPT课件.ppt

EPISTAXIS,Glen Porter,MDFrancis B.Quinn,MDUTMB-GalvestonGalveston,Texas-吴彦桥主持讲解,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,AnatomyNasal cavityVascular supplyPhysiologyVascular natureMucosa,Why bleeding from the nose?,Vascular organ secondary to incredible heating/humidification requirementsVasculature runs just under mucosa(not squamous)Arterial to venous anastamosesICA and ECA blood flow,Anatomy of the Lateral Nasal Wall,SPF-class I(35%)-class II(56%)-class III(9%),Sphenopalatine foramen(SPF)Class,Class 1:the opening of the SPF is purely into the superior meatus,Class 2:the SPF spans the ethmoidal crest(i.e opens to both superior and middle meati,Class 3:there are two separate opening into the superior and middle meati,External Carotid Artery-Sphenopalatine artery-Greater palatine artery-Ascending pharyngeal artery-Posterior nasal artery-Superior Labial arteryInternal Carotid Artery-Anterior Ethmoid artery-Posterior Ethmoid artery,Pterygopalatine Vasculature-Internal maxillary artery,Anatomy of the Nasal Cavity and Vasculature,Sphenopalatine AAEthmoid AAGreater 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 ostiumAnterior:younger,usually septal vs.anterior ethmoid,most common(90%),typically less severePosterior:older population,usually from Woodruffs plexus,more serious.,Etiology,Local factorsVascularInfectious/InflammatoryTrauma(most common)IatrogenicNeoplasmDessicationForeign Bodies/other,Etiology,Systemic factorsVascularInfection/InflammationCoagulopathy,Local Factors-Vascular,ICA Aneurysms extradural cavernous sinus,Local Factors-Infection/Inflammation,Rhinitis/SinusitisAllergicBacterialFungalViral,Local Factors-Trauma,Nose pickingNose blowing/sneezingNasal fractureNasogastric/nasotracheal intubationTrauma to sinuses,orbits,middle ear,base of skullBarotrauma,Nasal Fracture with Septal Hematoma,Local Factors-Iatrogenic nasal injury,Functional endoscopic sinus surgeryRhinoplastyNasal reconstruction,Local Factors-Neoplasm,Juvenile nasopharyngeal angiofibromaInverted papillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphoma,Local Factors Dessication,Cold,dry airmore common in wintertimeDry heatPhoenix and Death valleyNasal oxygenAnatomic abnormalitiesAtrophic rhinitis,Local Factors-Other,Self-inflicted(pedi)vs.traumatic foreign bodiesIntranasal parasitesSeptal perforationChemical(cocaine,nasal sprays,ammonia,etc.),Systemic Factors-Vascular,Hypertension/ArteriosclerosisHereditary Hemorrhagic Telangectasias(OWR),Systemic Factors Infection/Inflammation,TuberculosisSyphillisWegeners GranulomatosisPeriarteritis nodosaSLE,Systemic Factors Coagulopathies,ThrombocytopeniaPlatelet dysfunctionSystemic disease(Uremia)drug-induced(Coumadin/NSAIDs/Herbal supplements)Clotting Factor DeficienciesHemophiliaVonWillebrands diseaseHepatic failureHematologic malignancies,Etiology and Age,Childrenforeign body,nose picking,nasal diptheria(1/3 with chronic bleeds have coagulation d/o)Adultstrauma,idiopathicMiddle agetumorsOld age-hypertension,Initial Management,ABCsMedical history/MedicationsVital signsneed IV?Physical examAnterior rhinoscopyEndoscopic rhinoscopyLaboratory examRadiologic 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/plateletsPressure/Expulsion of clotsTopical decongestants/vasocontrictorsCautery(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/emolientsDiscontinue offending medsNasal saline spraysAvoidance of nose picking/blowingSneeze with mouth openAvoid straining/bedrest,Nasal packs,Anterior nasal packsTraditionalRecent modificationsPosterior nasal packsTraditional Recent modificationsAnt/Post nasal packing,Pick a Pack,any pack,Pick a pack to pack with,TSSNugauze vs.MerocelElectron microscopy,Posterior Packs Admission,Elderly and those with other chronic diseases may need to be admitted to the ICUContinuous cardiopulmonary monitoringAntibioticsOxygen supplementation may be neededMild sedation/analgesiaIVF,Indications for surgery/embolization,Continued bleeding despite nasal packingPt requires transfusion/admit hct of 72hrs(wang vs.schaitkin),Selective Angiography/embolization,Helps identify location of bleedingEmbolization most effective in patients whoStill bleeding after surgical arterial ligationBleeding site difficult to reach surgicallyComorbidities prohibit general anestheticEffective only when bleeding is.5 ml/min90+%success rate,complication rate of 0.1%Only able to embolize external carotid&branchesComplications:minor(18-45%)/major(0-2%)Contraindicated in bad atherosclerosis,Ethmoid bleed,Surgical treatment,Transmaxillary IMA ligationIntraoral IMA ligationAnterior/Posterior Ethmoidal ligationTransnasal Sphenopalatine ligationExternal carotid artery ligationSeptodermoplasty/Laser ablation,Transmaxillary IMA ligation,Waters view Caldwell-LucElectrocautery of posterior wall before removalMicroscopic dissection and ligation of IMA-descending palatine&sphenopalantine most importantRecurrence rate(failure rate)of 10-15%Complication rate of 25-30%(oa fistula,dental,n),Intraoral IMA ligation,Posterior gingivobuccal incision beginning at second molarTemporalis mm split and partially dissectedIMAX visualized,clipped and dividedAdvantages:children/facial fracturesDisadvantages:more proximal ligationComplications: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 unclearLynch incisionFronto-ethmoid suture line12-24-6(14-18,8-10,4-6),Transnasal Endoscopic Sphenopalatine Artery ligation,Follow Middle Turbinate to posteriormost aspectVertical mucoperiosteal incision 7-8mm anterior to post middle turb(between mid.and inf.turbs)Elevation of flapID neurovascular bundle at foramenLigation with titanium clipReapproximate flapComplications few,Failures0-13%,Transnasal Spheno-palatine Artery ligation,ECA ligation,EffectivenessAnterior border of SCMID ECA/ICALigation after clear that surrounding structures are safe.,Septodermoplasty/Laser,Remove mucosa from anterior septum,floor of nose,lateral wallSTSG vs.cutaneous,myocutaneous,microvascular free flaps vs.AutograftsNeodymium-yttrium-garnet(Nd-YAG)laser or Argon laser+topical steroid best nonsurg rx for mild/mod diseaseStill bleed,but not as badDefinitive 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 equalFailure 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 rebleedsCautery does not work with no platelets/clottingGlove packingH2O2Merocels(2 or more)injected with cortisporin oticAmicar spray,Tips and Pearls,Hot water irrigationCold water irrigationSalt PorkDont pack nose in unconscious person with suspected skull fractures.Antibiotic cream vs.silver nitrateIntranasal pressureEstrogen cream to nasal septum,Tips and Pearls,Transnasal endoscopic bipolar cautery of sphenopalatine artery(7%failure in pts with obvious source of bleed)Submucosal supraperichondrial dissection of nasal septumNot all hospitals have embolization-trained interventionalistsNo hard-set outline.Do what is best for your particular patient,典型录像,下鼻道后端：鼻后外侧动脉出血中鼻甲下端：鼻后外侧动脉中鼻甲支下鼻甲上缘：鼻后外侧动脉分支鼻中隔上端：筛前动脉鼻中隔前端：筛前动脉末端等,鼻内镜下止血,门诊止血成功率大约95需要鼻内镜手术并止血的：鼻中隔偏曲合并鼻出血，眶壁骨折合并鼻出血，鼻腔肿物或鼻窦肿瘤合并鼻出血需要栓塞的：颈内动脉假性动脉瘤，颈内动脉海绵窦动静脉瘘,