Aspirin Resistance 2003 08 13

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1 : EPISTAXIS EPISTAXIS Means Bleeding from Nose. It is only a symptom and not a disease. It is a manifestation of a local or a general disease. It is a common condition. And occur at any age.
2 : CAUSES OF EPISTAXIS:- A. Local:- Congenital Osler weber rendu disease. (Hereditary hemorrhagic telangiengiectasis) Is a familial disease Characterised by traid of epitaxis multiple mucosal and cutaneous telengectasia mulitiple capillary haemangiomas in the nose
3 : Acquired Causes:- Traumatic:- Fractures of nose Operations e.g. SMR, Polypectomy etc. Nose picking is most common nest cause bleeding. B. Barotrauma Nose blowing High altitudes
4 : Inflammatory:- Acute:- Non specific rhinitis e.g. coryza Specific rhinitis e.g. diphtheria, adenoiditis, sinusitis etc. Chronic:- Non specific e.g. atrophic rhinitis Specific e.g. scleroma. Rhinosporidiosis, chronic sinusitis . Midline nasal granuloma & granulomas like tuberculosis, syphilis leprosy and lupus may produce scanty bleeding.
5 : Neoplasms:- Benign Angiomatous polyp Papilloma Nasoharyngeal angiofibroma Mallignant Carcinoma Sarcoma of the sinuses / nasopharynx. Miscellaneous:- Foreign body Rhinolith Nasal parasites High altitudes and extreme temparatures
6 : SYSTEMIC CAUSES:- Cardiovascular Disease Hypertension Rheumatic heart disease Pulmonary hypertension Infective Endocarditis
7 : Blood disorders:- Christmas disease Hemophilia Purpura Aplastic anemia Drugs:- Salicylates Quinine General conditions:- Renal conditions Hepatic disease Vicarious menstruation in females due to ectopic edndometrial tissue if Present in the nose. Septicemia IDIOPATHIC
8 : COMMON SITES OF EPISTAXIS:- Nasal Septum:- Little’s area accounts for almost 90% of cases. There maybe a spot on or behind the spurs. Above the middle turbinate:- Anterior ethmoidal vessels may bleed due to hypertension. Woodruff’s plexus behind the posterior end of the inferior turbinate may be a factor. Prognosis depends upon the cause
9 : INVESTIGATIONS:- Vital parameters – shock detected Hemoglobin – anemia Coagulation tests – bleeding disorders Radiology – sinusitis, fractures, tumour Nasal endoscope Biopsy – malignancy
10 : MANAGEMENT OF EPISTAXIS:- Immediate:- Pressure – by compression of the nose between the thumb and first two fingers. Ice cold packs – applied on the bridge of the nose, which may stop the bleeding by reflex vasoconstructions. Trotter’s method –the patient is made to sit upright and incline forwards with mouth open and pinched (self) nostrils, then asked to breathe out quietly spitting out all the blood from the pharynx.
11 : B. LOCAL MANAGEMENT:- Cautery:- If the bleeding point is visible, it may be cauterized with 50% trichloracetic acid. Sometimes electrocautery maybe required. Nasal endoscopy may be utilized for identifying and cauterizing the bleeding point. Cryo Cautery is direct application of the probe tip.
12 : 2. Nasal Packing:- Anterior packing:- If epistaxis persists the nose is packed with ribbon gauze impregnated with lubricant like Vaseline or liquid paraffin. If un Lubricanted pack is used, it sticks to the nasal mucosa and its removal becomes difficult, painful and fresh bleeding recurs. The nose is packed from bottom to top in layers, like. The packs are removed after 48 hours.
13 : Posterior nasal packing :- It is done by drawing a post nasal pack to the nasopharynx with the help of two rubber catheters through the nostrils. An anterior nasal packs again required here to keep this pack in place. This procedure is performed under general anesthesia in a hospital Adrenaline packs are not recommended as they may raise blood pressure and may lead to recurrence of epistaxis due to rebound congestion after some time.
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15 : Foley catheter:- May be used to control postnasal bleeding and is less uncomfortable than postnasal packing.
16 : LUBRICANTS:- If the bleeding is due to crusting in the vestibule of the nose as in rhinitis sicca, application of any lubricant in the nose like an ointment Vaseline ghee oil or butter prevents crust formation.
17 : SYSTEMIC MANAGEMNT Bloodpressure:- Should be checked to detect pretension and to assess the blood loss. Hypotensive drugs are administered to control hypertension. Pulse and Respiration should be monitored. Replacement of the blood lost is carried out Shock is treated, if present.
18 : Coagulants like calcium, vitamin C, vitamin K, ethamsylate and carbazochrome salicylate are routinely used, but their efficacy is doubtful. In an emergency, fresh blood transfusion replaces the blood lost and provides all the known and unkown factors of coagulation. Antibiotics are administered to prevent infection following nasal packing. Sedatives maybe advised to allay apprehension
19 : SURGICAL MANAGEMENT:- Ligation:- Intractable cases of epistaxis may require the ligation of external carotid artery maxillary artery, or anterior ethmoidal artery.
20 : Maxillary artery is ligated by clipping it in the pterygopalatine fossa via caldweel – luc operation.
21 : Anterior ethmoidal artery is ligated by an incision below the medial part of the eyebrow, the incision is made uptothe periosteum. Where the artery is seen entering from the orbit into the nose is ligated.
22 : SEPTAL DERMOPLASTYIS performed when severe, difficult to manage bleeding is recurrent in hereditary hemorrhagic telangiectasis (Osler’s disease). Essentially, this operation replaces the mucosa containing the prominent vessels with oral mucosa or a split thickness graft.
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24 : Submoucs resection or septoplasty of the nasal septum is occasionally perfromed to gain access to the bleeding point in a patient having severe deviation of the nasal septum, which then permits proper access to control epistaxis.


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