NON-TRAUMATIC CONDITIONS OF THE NOSEENT emergencies 403MANAGEMENT
1 Bleeding from Little’s area
(i) Pinch the anterior part of the nose for 10 min with the patient
sitting forward until the bleeding stops. Forbid the patient to
pick, blow or sniff through the nose to prevent recurrence of the
epistaxis.
(ii) Identify with suction or by swabbing if a bleeding point persists,
and anaesthetize the area with a cotton-wool pledget soaked in
4% lignocaine (lidocaine) with adrenaline (epinephrine).
(iii) Cauterize the bleeding point with a silver nitrate stick touched onto
the area for 10 s. Avoid overzealous application or cauterization to
both sides of the septum, as these will lead to septal necrosis.
2 Persistent anterior bleeding and failed cautery
(i) Anterior nasal tamponade
Insert an epistaxis balloon catheter or Merocel™ nasal tampon, both of
which are far easier and less distressing to insert than formal packing.
(ii) Anterior nasal pack
(a) cover the patient and yourself with protective drapes when
no nasal tamponade device is available, and wear a face mask
and goggles
(b) apply further local anaesthetic with cotton-wool pledgets
soaked in 4% lignocaine (lidocaine) with adrenaline
(epinephrine). Remember the maximum dose is 7 mg/kg or
12 mL, i.e. approximately 500 mg lignocaine (lidocaine) with
adrenaline (epinephrine) in a 65 kg patient
(c) use 2 cm petroleum-jelly gauze or a calcium alginate
(Kaltostat™) 2 g pack
(d) insert successive layers horizontally along the floor of the
nose using Tilley’s nasal dressing forceps (see Fig. 13.1)
(a) (b)Figure 13.1 Anterior nasal packing
(a) Introducing the first loop horizontally along the floor of the nose, and (b) building the
layers horizontally upwards until pack is in place.