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 Sering Jarang
Trauma wajah Mukosa kering Hereditary Tuberkulosis
Trauma digiti Inhalasi kimiawi Hemorrhagic Mononukleosis
Benda asing Barotrauma Telangiectasia (HHT) Demam scarlet
Perforasi septum Sinusitis Leukemia Demam reumatik
Deviasi atau spina Rinitis Trombositopenia Sifilis
septum Lesi metastatik Anti platelet (aspirin, Penyakit hepar
Polip hidung Angiofibroma juvenil clopidogrel) Uremia
Tumor sinonasal Iritasi lingkungan Polisitemia vera ISPA
Tumor nasofaring Anemia aplastik
Hemangioma hidung Hemofilia
Obat antikoagulan
(heparin, warfarin)
Defisiensi vitamin K
Penyakit Von
4 Willebrand
 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

29
 EPISTAKSIS

-Anamnesis riwayat
penyakit, tentang Syok
perdarahan, riwayat hipovolemik,
trauma, penggunaan penderita tua, Resusitasi
obat2an, kebiasaan risiko cairan
merokok/ alkohol perdarahan
profus
-Pemeriksaan Klinis/
Laboratorium
30
Identifikasi lokasi perdarahan -Evaluasi dan
(rinoskopi anterior, terapi kausa untuk
nasoendoskopi rigid/fleksible): mencegah
-Anterior Berhasil kekambuhan
-Posterior -Edukasi &self
-Lokasi perdarahan tidak care penderita
jelas untuk mencegah
kekambuhan

Tindakan lokal menghentikan

perdarahan:
-kauter (kimiawi/ elektrik)
-tampon hidung ( anterior & posterior)

Tidak berhasil
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Tindakan lokal -Evaluasi dan terapi
menghentikan kausa untuk mencegah
perdarahan: kekambuhan
-kauter (kimiawi/ -Edukasi &self care
elektrik) penderita untuk
-tampon hidung mencegah
(anterior & posterior) kekambuhan

Tidak berhasil Tidak ada perdarahan

lagi

Tampon hidung
Berhasil Angkat tampon
ulang
48-72 jam

Perdarahan tidak berhenti

32
 Tampon hidung ulang -Evalusi dan terapi
kausa untuk mencegah
kekambuhan
Perdarahan tidak -Edukasi &self care
penderita untuk
berhenti mencegah
kekambuhana
Gangguan faal
perdarahan Identifikasi Berhasil
kausa

Konsultasi-rawat bersama
Koreksi gangguHematologis-
onkologis:
Koreksi gangguan koagulopati:
-FFP - vit K
-cryprecipitate -trombosit
Penatalaksanaan dengan fibrin glue 33
 Tampon hidung ulang

-Evaluasi dan terapi

Perdarahan tidak berhenti kausa untuk
mencegah
kekambuhan
Gangguan faal Identifikasi -Edukasi &self care
perdarahan (-) kausa penderita untuk
mencegah
kekambuhan
Intervensi pembedahan:
-Septum koreksi
-Ligasi arteri karotis eksterna
-Ligasi arteri maxillaris interna Berhasil
-Ligasi arteri sfenopalatina
-Ligasi arteri etmoidalis
Embolisasi arteri maksilaris & cabangnya
Radiasi (kasus-kasus malignansi)
Kasus HHT (Laser, fibrin glue, nasal obliterasi) 34
 Angkat tampon 48-72 jam

-Evaluasi dan terapi

Perdarahan berulang kausa untuk
mencegah
kekambuhan
Gangguan faal -Edukasi &self care
perdarahan (-) Identifikasi kausa
penderita untuk
mencegah
kekambuhan
Intervensi pembedahan:
-Septum koreksi
-Ligasi a.karotis eks/Ligasi a. Maks.int/
Ligasi a. Sfenopalatina/ Ligasi a.
Etmoidalis. Berhasil
-Embolisasi a.maksilaris & cabangnya
-Radiasi (kasus-kasus malignansi)
-Kasus HHT (Laser, fibrin glue, nasal
obliterasi) 35
Terima Kasih