Penanganan Epistaksis Wijaya Juwarna THT RSU Permata Bunda & Columbia Asia Medan
Biodata Singkat • Dr. Wijaya Juwarna, M.Ked (ORL-HNS), Sp.THT-KL • Belawan, 26 Mei 1980 • FK USU, 2005 • THT USU, 2014 • Sekretaris IDI Cabang Medan, 2013 – sekarang • RS Permata Bunda & Columbia Asia Medan
Epidemiologi Sekitar 60% populasi pernah mengalami 1 episode epistaksis dalam hidupnya 6% populasi membutuhkan penanganan medis dan 1,6 dari 10.000 membutuhkan rawat inap Laki-laki lebih sering ditemukan sekunder akibat trauma Insidensi usia distribusi bimodal dengan puncak pada anak dan dewasa tua (usia 45-65 tahun) 3
Etiologi Lokal
Sistemik
Sering
Jarang
Trauma wajah Trauma digiti Benda asing Perforasi septum Deviasi atau spina septum Polip hidung Tumor sinonasal Tumor nasofaring Hemangioma hidung
Mukosa kering Inhalasi kimiawi Barotrauma Sinusitis Rinitis Lesi metastatik Angiofibroma juvenil Iritasi lingkungan
Sering Hereditary Hemorrhagic Telangiectasia (HHT) Leukemia Trombositopenia Anti platelet (aspirin, clopidogrel) Polisitemia vera Anemia aplastik Hemofilia Obat antikoagulan (heparin, warfarin) Defisiensi vitamin K Penyakit Von 4 Willebrand
Jarang Tuberkulosis Mononukleosis Demam scarlet Demam reumatik Sifilis Penyakit hepar Uremia ISPA
Klasifikasi Epistaksis
• •
Epistaksis anterior: area Little (pleksus Kiesselbach) anastomosis a. etmoid anterior dan posterior, a. sfenopalatina cabang septal, a. palatina mayor, a. labialis superior Epistaksis posterior: pleksus Woodruff anastomosis a. sfenopalatina, a. palatina descenden dan kontribusi kecil dari a. etmoid posterior 5
Sumber Perdarahan Septum Nasi
Vaskularisa si Dinding Medial dan Lateral Hidung
Riwayat Pasien • Previous bleeding episodes • Nasal trauma
• Family history of bleeding • Hypertension - current medications and how tightly controlled
• Hepatic diseases • Use of anticoagulants
• Other medical conditions - DM, CAD, etc.
Physical Exam - Equipment • • • • • • • •
Protective equipment - gloves, safety goggles Headlight if available Nasal Speculum Suction with Frazier tip Bayonet forceps Tongue depressor Vasoconstricting agent (such as oxymetazoline) Topical anesthetic
Therapeutic Equipment to be Available • Variety of nasal packing materials • Silver nitrate cautery sticks • 10cc syringe with 18G and 27G 1.5inch needles • Local anesthetic for prn injection • Gelfoam, Collagen absorbable hemostat, Surgicel or other hemostatic materials.
General Epistaxis Supplies
Physical Exam • Measure blood pressure and vital signs • Apply direct pressure to external nose to decrease bleeding • Use vasoconstricting spray mixed with tetracaine in a 1:1 ratio for topical anesthesia • IDENTIFY THE BLEEDING SOURCE
Types of Nosebleeds • ANTERIOR – Most common in younger population – Usually due to nasal mucosal dryness – May be alarming because can see the blood readily, but generally less severe – Usually controlled with conservative measures
Types of Nosebleeds • POSTERIOR – Usually occurs in older population – HTN and ASVD are common contributing factors – May also have deviation of nasal septum – Significant bleeding in posterior pharynx – More challenging to control
Traditional Anterior Pack
Usually, 1/2 inch Iodiform or NuGauze is used. Coat the gauze with a topical antibiotic ointment prior to placement.
Other Anterior Nasal Packs • Formed expandable sponges are very effective • Available in many shapes, sizes and some are impregnated with antibacterial properties
Correct direction for placement of nasal packing
Treatment of Posterior Epistaxis • IV pain medication and antiemetics may be helpful • Use topical anesthetic and vasoconstrictive spray for improved visualization and patient comfort • Balloon-type episaxis devices often easiest • Foley catheter or other traditional posterior packs may be necessary
Traditional Posterior Pack
Posterior Balloon Packing • Always test before placing in patient • Fill “balloons” with water, not air • Orient in direction shown • Fill posterior balloon first, then anterior • Document volumes used to fill balloons
Complications of Posterior Packs • Must be careful after placement of a posterior pack to avoid necrosis of the nasal ala • Often this can be avoided by repositioning the ports of the balloon pack and close monitoring of the site
Patients with Nasal Packing • Best to place patient on a p.o. antibiotic to decrease risk of sinusitis and Toxic Shock Syndrome • Advise pt to avoid straining, bending forward or removing packing early • If other nostril is unpacked, advise topical saline spray and saline gel to moisturize nasal mucosa
Patients with Nasal Packing • Most patients may be treated as outpatients but hospital admission and observation should be strongly considered when a posterior pack is used. SaO2 should be monitored as well. • Admission may also be prudent for those with CAD, severe HTN or significant anemia. Give supplemental oxygen via humidified face tent.
Greater Palatine Foramen Block • Mechanism of action is volume compression of vascular structures • Lidocaine 1% or 2% with epinephrine 1:200,000 used or Lidocaine with sterile water. • Do not insert needle more than 25mm
Preventive Measures • Keep allergic rhinitis under control. Use saline nasal spray frequently to cleanse and moisturize the nose. • Avoid forceful nose blowing • Avoid digital manipulation of the nose with fingers or other objects • Use saline-based gel intranasally for mucosal dryness • Consider using a humidifier in the bedroom • Keep vasoconstricting spray at home to use only prn epistaxis
Tujuan penanganan epistaksis Mengontrol perdarahan aktif, mencari lokasi dan penyebab perdarahan
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EPISTAKSIS Anamnesis riwayat penyakit, tentang perdarahan, riwayat trauma, penggunaan obat2an, kebiasaan merokok/ alkohol -
-Pemeriksaan Klinis/ Laboratorium
Syok hipovolemik, penderita tua, risiko perdarahan profus
Resusitasi cairan
30
Identifikasi lokasi perdarahan (rinoskopi anterior, nasoendoskopi rigid/fleksible): -Anterior -Posterior -Lokasi perdarahan tidak jelas
Berhasil
-Evaluasi dan terapi kausa untuk mencegah kekambuhan -Edukasi &self care penderita untuk mencegah kekambuhan
Tindakan lokal menghentikan perdarahan: -kauter (kimiawi/ elektrik) -tampon hidung ( anterior & posterior)
Tidak berhasil 31
Tindakan lokal menghentikan perdarahan: -kauter (kimiawi/ elektrik) -tampon hidung (anterior & posterior)
-Evaluasi dan terapi kausa untuk mencegah kekambuhan -Edukasi &self care penderita untuk mencegah kekambuhan Tidak ada perdarahan lagi
Tidak berhasil
Tampon hidung ulang
Berhasil
Angkat tampon 48-72 jam
Perdarahan tidak berhenti 32
Tampon hidung ulang Perdarahan tidak berhenti Gangguan faal perdarahan
Identifikasi kausa
Konsultasi-rawat bersama Koreksi gangguHematologisonkologis: Koreksi gangguan koagulopati: -FFP - vit K -cryprecipitate -trombosit Penatalaksanaan dengan fibrin glue
-Evalusi dan terapi kausa untuk mencegah kekambuhan -Edukasi &self care penderita untuk mencegah kekambuhana
Berhasil
33
Tampon hidung ulang
Perdarahan tidak berhenti Gangguan faal perdarahan (-)
Identifikasi kausa
Intervensi pembedahan: -Septum koreksi -Ligasi arteri karotis eksterna -Ligasi arteri maxillaris interna -Ligasi arteri sfenopalatina -Ligasi arteri etmoidalis Embolisasi arteri maksilaris & cabangnya Radiasi (kasus-kasus malignansi) Kasus HHT (Laser, fibrin glue, nasal obliterasi)
-Evaluasi dan terapi kausa untuk mencegah kekambuhan -Edukasi &self care penderita untuk mencegah kekambuhan
Berhasil
34
Angkat tampon 48-72 jam
Perdarahan berulang Gangguan faal perdarahan (-)
Identifikasi kausa
Intervensi pembedahan: -Septum koreksi -Ligasi a.karotis eks/Ligasi a. Maks.int/ Ligasi a. Sfenopalatina/ Ligasi a. Etmoidalis. -Embolisasi a.maksilaris & cabangnya -Radiasi (kasus-kasus malignansi) -Kasus HHT (Laser, fibrin glue, nasal obliterasi)
-Evaluasi dan terapi kausa untuk mencegah kekambuhan -Edukasi &self care penderita untuk mencegah kekambuhan
Berhasil
35
Terima Kasih
