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malposition of the cuff in the subglottic area. If a
chest tube is present, check for air leak.
10. Weaning from mechanical ventilation
a. Consider extubation in patients with
cardiovascular stability, a high PaO2/FiO2
ratios (>200) on low PEEP, and those able to
protect their airway.
b. The most common weaning method is the
daily trial of spontaneous breathing. While at
the bedside, the patient is placed on CPAP
and allowed to breath on his own. If the
respiratory rate/tidal volume ratio is
patients are rested on the previous settings
until the next day.
c. If they fail the T-tube trial, or their respiratory
rate to tidal volume ratio is >100, they are
rested on the previous settings until the next
day.
Epistaxis
Roger Crumley, MD
Almost all persons have experienced a nosebleed at
some time, and most nosebleeds resolve without
requiring medical attention. Prolonged epistaxis,
however, can be life-threatening, especially in the elderly
or debilitated.
I. Pathophysiology
A. Anterior epistaxis, in the anterior two thirds of the
nose, is usually visible on the septum and is the
most common type of epistaxis. The anterior
portion of the septum has a rich vascular supply
known as Kiesselbach's plexus or Little's area, and
most epistaxis originates in this region. Anterior
bleeding can often be stopped by pinching the
cartilaginous part of the nose.
B. Posterior epistaxis from the posterior third of the
nose accounts for 10% of nosebleeds. Bleeding is
profuse because of the larger vessels in that
location. It usually occurs in older patients, who
have fragile vessels because of hypertension,
atherosclerosis, coagulopathies, or weakened tis­
sue. Posterior bleeds require aggressive treatment
and hospitalization.
II. Causes of epistaxis
A. Trauma. Nose picking, nose blowing, or sneezing
can tear or abrade the mucosa and cause bleed­
ing. Other forms of trauma include nasal fracture
and nasogastric and nasotracheal intubation.
B. Desiccation. Cold, dry air and dry heat contribute
to an increased incidence of epistaxis during the
winter.
C. Irritation. Upper respiratory infections, sinusitis,
allergies, topical decongestants, and cocaine
sniffing may cause bleeding.
D. Less common causes of anterior epistaxis include
Wegener's granulomatosis, mid-line destructive
disease, tuberculosis, syphilis, and tumors.
Epistaxis is exacerbated by coagulopathy, blood
dyscrasia, thrombocytopenia, or anticoagulant
medication (NSAIDs, warfarin), hepatic cirrhosis,
and renal failure.
E. Hypertension complicates active bleeding by
promoting rigid arteries, and arteriosclerosis
weakens vessels.
III.Clinical evaluation of epistaxis
A. The airway, breathing and circulation should be
maintained. Hemodynamic evaluation for
tachycardia, hypotension, or light-headedness
should be completed immediately. Hypovolemic
patients should be resuscitated with fluids and
packed red blood cells. Oxygen should be
administered and intravenous access established.
When inserting the intravenous line, it is convenient
to obtain blood for complete blood count and, if
clinically indicated, type and screen, coagulation
profile, and electrolytes.
B. After stabilization, the site, cause, and amount of
bleeding should be determined. Most patients do
not require resuscitation. Posterior epistaxis in an
elderly and debilitated patient can be life­
threatening.
C. Determine the side of bleeding. Unilateral nose
bleeding suggests anterior epistaxis in
Kiesselbach's plexus. Bilateral bleeding suggests
posterior epistaxis caused by overflow around the
posterior septum.
D. Determine whether epistaxis is anterior or pos-
terior: When the patient is upright, blood drains
primarily from the anterior part of the nose in
anterior bleeding, or it drains from the nasopharynx
in posterior bleeding.
E. Assess the duration of the nosebleed and any
inciting incident (eg, trauma). Swallowed blood
from epistaxis may cause melena. Hypertension,
bleeding disorders, diabetes, alcoholism, liver
disease, pulmonary disease, cardiac disease and
arteriosclerosis should be assessed.
F. Medications including aspirin, NSAIDs, warfarin,
nasal sprays, and oxygen via nasal cannula should
be sought.
G. Blood tests. Hematologic tests include CBC,
platelet count, INR, partial thromboplastin time, and
blood for type and cross. The hematocrit does not
immediately drop in acute hemorrhage.
IV. Localization of the site of bleeding
A. Sedation. When sedation is required, midazolam
(Versed), 1-2 mg IV in adults and 0.035-0.2 mg/kg
IV in children is recommended; overmedication
may threaten the cough reflex which protects the
airway.
B. Drape the patient, and furnish an emesis basin.
Keep the patient sitting upright or leaning forward.
A gown, gloves, mask, and protective eyewear [ Pobierz całość w formacie PDF ]

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