SIW “Nasal bleeding tamponade”

1. SIW “Nasal bleeding tamponade”

2. Plan

I.
II.
III.
IV.
Introduction
Basic part
Conclusion
References

3. Introduction

•Anterior nasal packing is the commonest
type of packing used for the management of
epistaxis, when initial treatment by pressure
and cautery are failed.

4. REASON FOR EXCESSIVE BLEEDING

• Rich vascularity
• Supplied by both internal and external carotid system
• Various anastomoses between arteries and veins
• Blood vessels run under the mucosa unprotected
• Larger vessels on the turbinate run in bony canals – cannot
contract

5.

• 90 % of epistaxes are
anterior, originating
from the Kiesselbach
plexus (see the image
below). Anterior
epistaxes exhibit
unilateral, steady, nonmassive bleeding. Just
10% of epistaxes are
posterior, exhibiting
massive bleeding that
is initially bilateral.

6.

7.

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

8.

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).

9.

Contraindications
• Patients with respiratory compromise may first require airway
control and mechanical ventilation. Patients with hemodynamic
compromise may first require volume and blood product
resuscitation.

10. Technique

Preparation (Anesthesia)
• Topical anesthetics include a 2% (or 4%) solution
of lidocaine
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 [ie, 0.25
mg]) plus lidocaine (20 mL 2% [ie, 400 mg])

11. Equipment

Equipment includes the following:
• Gloves
• Eye shield
• Procedure lighting (best to use a headlamp)
• Tape
• Cotton
• Tongue depressors

12.

• Commercially produced nasal tampon - Gelfoam (absorbable gelatin),
Surgicel (oxidized cellulose), Merocel nasal tampon (see the first and
second images below)
• Rapid Rhino anterior balloon tampon (see the third image below)
• Topical vasoconstrictors and 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)
• Epistaxis tray, which at some institutions includes many of the
components mentioned above (see the seventh image below)

13.

Smaller Merocel epistaxis pack.
Merocel nasal packing with airway, 8 cm.
Rapid Rhino anterior balloon tampon.
Frazier suction tip.
Epistaxis tray.
Nasal speculum.
Silver nitrate sticks.

14. Positioning

• Place the patient in an upright, not a recumbent, position (see the
images below) unless hemodynamic instability prevents this
positioning.
Patient sitting in an inappropriate, reclined position.
Patient sitting in an appropriate, upright position.

15.

• Anterior packing with prefabricated nasal tampons begins with applying
anesthetic to the nasal mucosa with cotton balls or via inhalation. Apply
surgical lubricant to the tampon, and gently insert it to 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 into the nose and expanded by application of
water. The nasal tampon swells and fills the nasal cavity and applies pressure
over the bleeding point. The Merocel tampon is believed to aggregate clotting
factors to reach a critical level, thereby promoting coagulation. The Merocel
success rate is 85% (equal to that of traditional ribbon gauze).
• The Rapid Rhino anterior balloon tampon is made of carboxymethylcellulose, a
hydrocolloid material. It acts as a platelet aggregator and also forms a lubricant
upon contact with water. Unlike 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.

16. 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 and a nasal speculum to place
the gauze in a layered, accordion
fashion, packing it from anterior to
posterior (see the image below). The
gauze should be placed as far
posteriorly as is possible.

17.

18. Complications(post-procedure)

• Hemorrhagic shock
• Septic shock
• Pneumocephalus
• Sinusitis
• Septal pressure necrosis
• Neurogenic syncope during packing
• Epiphora (from blockage of the lacrimal duct)
• Hypoxia (from impaired nasal air movement)
• Staphylococcal toxic shock syndrome

19. Conclusion

• While site of packing (anterior vs. posterior), sterility
of the environment (operative room vs. ED), and entry
into nasal cavity (post-surgical vs. non-instrumented)
may have some effect on the incidence of infectious
outcomes.

20. References

• https://emedicine.medscape.com/article/80526-overview#a4
• https://entsho.com/anterior-nasal-packing/