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And stuff. So, um yesterday, what we did was that we released the feedback form after the session was ended today, what we'll do is before the session ends, we will just put the feedback form in the chat. So everybody who is attending the session, when you complete that form, you will be able to download your certificate straight away. Uh One thing and the second concern was so I went through the feedback, uh the the people, the feedbacks that people have submitted. Uh And I was very glad to uh read that most of the feedback. I mean, almost all of the feedbacks were uh positive. People were very happy with the, the content that was uh presented yesterday. There were only a few concerns regarding directiveness of the session, which obviously, you know, there was a section in the feedback form where they were asking if we can improve this thing. So uh so improve. What? So if there was any way we could improve the session or the thing that we are conducting. So basically the the the only problem in terms of in terms of interaction. What did you mean in general? How you know, in general, in general, how we could improve this thing. Um And most people give this, give the suggestion that we could have made this more inter you understand what I mean to say? So the only problem that we have is, you know, the the platform that we are we are using right now, this platform has slight limitations. So uh it only gives speakers and the mediators to come on the screen, turn their cameras on and speak during the session and it has a limitation towards the viewers that they are not able to go like they are not able to speak. So I would like to apologize in advance regarding, regarding that limitation. But is there, is there an option where um they can post uh whatever they want to say on the chat and the future can occasionally look there and address them? Yes. No, no, no. So yesterday, what we did was I was on the chat throughout. Uh But yes, people are happy to put the chats in but they were only uh concerned if they were able to, you know, if they, if there's any way that they could come and speak uh during the session to be to make it more interactive. So we are happy to ans answer all your queries and all your concerns in the chart. But yes, we have this limitation, given the platform that we're using. So I'm very sorry about that. Um And yes, I think, I think that is all that I have to say I've been given to uh a and to continue from here onward then. Ok. So um good afternoon guys. Um My name is Neha. I'm one of the ent, this is my colleague Hamza. This is our second session of our ent teaching series and today's class is about epistaxis and it'll be taken by our below regar. Um Doctor A eve you can call her AU. Um, yeah, so very often we very often we see people who come into emergency with nose bleed and even one of our inpatients can suddenly have a nose bleed. So she will take us through the journey as in what to do immediately how to follow up these patients and what necessary investigations they need and the management. So au um, you can start now your class. Thank you. Thank you very much. Hi, everyone. Thanks very much for coming to this presentation today. I'll just pop up the powerpoint and, uh, then we can. So I have, I just, I just have a very brief input. Uh, before you start, I really like your fashion sense cycle. Yes. Yeah, I know. I'm a bit of a mixed bag today. Ok, let me get this show on the road. Um, one second. Can everyone see the screen? I'm sure that's a yes, I'm hoping that's a yes. Um, so hold on a second. Yep. So this is the presentation on Epistaxis. Um as my lovely colleague said earlier, my name is Aku. Um I'm one of the ent middle grades working at the Princess Royal. So it's really just a comprehensive overview um at the level really of a foundation doctor for how to manage Epistaxis. I hope you find this helpful. So first of all, I've just got a few learning objectives that we would like to touch on which were namely um the anatomy of the nose, basic anatomy of the nose in relation to nosebleeds, things that may cause nosebleeds, how they present um the clinical history um with questions which will be particularly tailored for you to get the salient information for how to manage your nose bleed. And then we're moving on to um basically, it's the management, so how to stabilize and examine the patient. And then finally, we'll move on to treatment. Ok. So first of all, what is epistaxis? Um Now, for anyone who speaks or understands Greek, um I hope I'm not getting this wrong. But my understanding is that epistaxis is split down into two meanings. Basically epi which is above and staxis, which is a dripping trickling. So basically just trickling from and just trickling down. It doesn't mention anything about the no, but we use it in relation to the nose. It's really what we we use the term for. Now, this is actually a very common ent problem. You will see it quite a lot. But when you look at how many people or the proportion of the population that presents with this. Um, very few actually come to the ear, nose and throat department. Um, obviously as nt specialist, it doesn't feel that way sometimes. But, um, it's actually really only 6% of the one in six that get nosebleeds that come to see us. So epistaxis can present as an emergency or as an elective problem. What I mean by that is they'll either come bundling into A&E with a really heavy or bad nose bleed that needs urgent attention or this is someone who gets nose bleeds from time to time and it may not be life threatening, but it causes them enough concern that they wish to have the matter addressed. So even as um a foundation doctor, you can see either of these presentations. So a bit bit of anatomy for um Epistaxis, I have left this blank. Um I've actually got my screen up to see the chat. So these are the blood vessels that supply the septum and parts of the um lateral wall of the nose. If anyone can type in the names of any of the vessels that they think they know that contribute to um the vascular supply of the nose. Um If anyone can type in the chat, I'll probably just wait for maybe 20 seconds or 30 seconds. See if anyone can type anything. They know I wanna try and make this interactive. So Oh, hold on one second. Can everyone actually see my screen? I think I may have actually got this. Um uh I might have lost the screen one second, right? Ok. Sorry, I don't know what happened there. Let me get the screen back up one second. Uh Oh, there we go. Sorry about that. Trying to make it interactive and I think I may have actually lost the plot with that. Um ok. Can you see the picture? Ok. So if anyone want to type in any of the vessels that they um think contribute to the supply of the nose, if you can see there, there's actually five vessels. If anyone can type um any ones that they think supply the nose, I'll wait for like maybe another 1015 seconds and then I'll change the slide. Anyone in the chat? OK. Maybe no one knows. So I will move the ne to the next slide. OK. So there are actually five major vessels that contribute to the, to the um supply of the nose. Um You have two that branch off from the um internal carotid artery and three that come off the external carotid artery. So these are the ones that you're seeing in the slide here. So the anterior and posterior ethmoid arteries and the superior labial and greater palatine, they mostly supply the anterior portion of the nose. And then you've got the spinal paat artery and the posterior ethmoid which supply the posterior part of the nose. Ok. So it might not be something you necessarily need to know, but it's actually quite helpful to know this. Um And a good way to remember the vessels is when I lift my upper lip, it makes me gasp. It's just a mnemonic to remember the blood vessels. Ok. And so that stands for the superior labial is the upper lip and then g for greater palatine. This one here, anterior ethmoid, this one here, spinal palatine here and a posterior ethmoid up here. OK. No, this one, I know this can look a little bit busy but just bear with me again. You've got the arteries here, the, the major players that supply the inside of the nose. But then you've got the two groups or a cluster of vessels that are often responsible for nosebleeds. You've got one at the front and one at the back. Now most people will be familiar with the one in the front. It's called little's area, also known as a case back plexus, as I say, it's contributing, it's been sorry, the vessels that contribute to this plexus originate mainly from these four vessels. The aides, the Gretta paat and the superior labial and they cause the nosebleeds that come from the front of the nose. Now, nosebleeds that come from the front of the nose that probably make up over 80% of the nose bleeds that you're going to see. So it's important to be aware of this little plexus here because when you examine inside of a patient's nose, a lot of the time you are going to be seeing the bleeding points coming from the very front of the nose. Ok. Now, there's also a mention of a plexus at the back of the nose. Ok. And this one is called woodruff's plexus. Now, Woodruff's plexus, there's some um I would say there's variation in the literature about what actually contributes to this. Is it a venous network or is it an arterial network? I would just say for the purposes of your practice. Now, a lot of bleeds that come from the back of the nose, um really are managed the same regardless of whether they're venous or arterial or whether you suspect they're venous or arterial. But the main contribution will often come from the sphenopalatine artery and it will often be in the septum rather than the lateral aspect of the nose. Ok. So that's that. Now, oops, there we go. So the next page is what actually causes nosebleeds. I'm very, I really love using my surgical sieve, which is something obviously most of us are familiar with from medical school, the vitamin CDE and then you can using the sib, you can actually tease what actually has caused the nose bleeds. Now, the ones that I've highlighted are probably the ones that you'll see actually not probably, but they are the ones you'll see in the majority of cases um that contribute to axis. Um So when we're talking about idiopathic, uh we're talking about, um, you know, presentations such as high BP, often we don't know, even for, for high BP, what, what causes it or it can be AIC, which is from surgeries that we ourselves perform. Then of course, you've got trauma very, very common and trauma is not just what you think of in the sense of someone hitting you in the nose. It can also actually be caused by picking the nose, um, or blowing the nose or sticking foreign bodies inside the nose. Foreign bodies are something we particularly see in Children. Environmental is also a common cause. And by environmental, I'm talking about allergens or irritants of the nose. So, um, things like pollen and that might cause someone to sneeze or blow their nose or even chemicals or irritants, um, or even things such as house dust mite or dust in and of itself. These are just examples. Now, there's a table that some people use to further categorize the causes. They can be local or systemic ie localized to just affecting the nose or they can be system wide in your body, but they also affect the nose. And I've put some examples here for you to refer to, um, as you'll be getting a copy of the slides afterwards, you can take your time to look at that. A few of the ones that I will just highlight that you might be less familiar with will be um, conditions such as endocrine in pregnancy. Pregnant women can get nosebleeds because of their hormonal changes that they go through. And so they can be pretty prone to nose bleeds and they often resolve after they've given birth. Um You can see patients that might have arterial vascular malformations and so and so unusual um vascular presentations that can leave them um prone to having nose bleeds. So you take your time to go through that. Um, when you can, now we'll go through the history of a nosebleed. Um, history of a nose bleed is, um, actually quite straightforward. Um, especially if the patient is sitting in front of you and bleeding, you can often pick up a lot of the history and without asking them, but it's always good practice to ask because sometimes the history can change even before they meet you. So you want to ask things such as obviously, when a nosebleed started, how long it's been going on for? Does, is it continuous? Does it stop and start? You want to know? Is it left-sided, right sided or bilateral? You want to get an idea if this is, if it's a, um, I say trauma, but really this will come under a precipitating factor. So, what has caused the nosebleed? Is it trauma or is it something else, um, such as, um, allergies or, um, the use of medications you want to know if the nosebleed is coming from the front or the back of the nose. How can you tell from that? A good way of telling is if the patient is bleeding from the front, um, obviously from the nostrils, you can tell it's from the front, but a lot of the time if they're also swallowing blood or if a lot of the blood is going into the mouth, then you'll actually be able to get a good idea that the bleeding is coming from the back. Um How heavy the bleed is. So a lot of patients will tell you about how many rolls of toilet paper they've gone through or cups or bowls of bled into. Honestly, they do tell you things like that and then you want to talk about previous episodes, this, this happened before, if it has happened before what has caused it and how did you manage it before? Did you just pinch your nose and everything was fine? Did you have to come into A&E did you require a blood transfusion past medical history? That will include touching on some of the points I've mentioned in the causes section. So you want to pick up anything that might give you further clue as to what has caused the bleed. It can be medical problems or it could be surgical problems. As I say, sometimes as surgeons, we cause nosebleeds. Um, so I raise my hand up, we've got to make sure we touch on that point, um, as well. Ok, medication history is very, very, very important because there are some patients, uh, who are supposed to, who have high BP that are prescribed antihypertensives, they might not be taking them. So it's good to know that they have a history of blood, of high BP. You also want to ask about any blood thinners they might be taking because that might either cause or prolong or exacerbate a bleed. And then of course, you want to ask about any nasal sprays they're using. So some patients use nasal sprays such as to treat um congestive problems in the nose. And sometimes the overuse of these agents can cause them to have nose bleeds. It's worth noting, you want to ask about allergies because allergies, like I say can trigger bleeds largely because of the irritation that causes in the nose. So if they're atopic or if they have known allergies to say grass pollen or dust or anything like that, you wanna ask about um first degree relatives. Um So does anyone in the family have nose bleeds? So you're thinking about um uh genetic conditions or coagulopathies, um hemophiliacs, for example, or people that have um telangiectasia and these are things that you want to ask or, or, or at least go in the background of your thinking and social history occupation. This matters because some people work in environments where they're exposed to a lot of dust or they work in environments that might cause them to have. Um Oh, sorry. Um, a and I'm still on the same slide. I haven't moved it yet. Um, or they might work in an occupation that might cause them to be exposed to um certain irritants that can um cause them to have nasal cancers, which in turn might cause nosebleeds. Alcohol, obviously, most of us know it can prolong bleeds, smoking again is another problem, recreational drug use. Um So patients that might use drugs such as cocaine, um that can precipitate nosebleeds and in living situation, not so much of a causative factor as something you might want to consider if a patient who's coming with a nosebleed is going home. Um Are they in a position to manage themselves if they go home and they've had a heavy bleed? A and I hope the slides are moving for you now. Ok. So stabilize. Um This will come under your initial observ observations. Um Oh, wonderful. Thanks Hamza. Um So your initial observations. So you're talking about whether you're meeting a patient in the acute or the elective setting, which guides first of all, um your initial approach, often in the acute setting, they are actively bleeding or they have recently bled and they might be vitally unstable. In that case, you need to think about your ABC SA. Lot of people think come on. It's only a nosebleed wise. I need to do ABC S clinical picture of nose bleeds can actually change quite rapidly. Um I mean, I haven't come across any cases but I mean, there is an historic case um of um a death, I think people have heard of the famous case of Attila, the hun who died of a nose bleed on his wedding night. So yes, nosebleeds can be very serious if not managed adequately in the acute setting. In the elective setting. Often these patients are not actively bleeding, they are stable and they can tell you everything that's going on. So you can take your sweet time examining them and often in those cases, ABC is not often necessary. Now, I say often not this very much depends on if you treat the patient in your clinic because then if you treat the patient in clinic and they start to bleed, then guess what you might need to do your ABC. So I hope we all remember what ABC S are. ABC S, air breathing circulation. Um Oh, sorry, I'm just looking at the chat. Uh Shama, I'll answer your question at the end about the drugs if that's ok. Um Hands if you can add it, that'd be awesome. Um So, um a air breathing circulation. So airway, you really want to make sure it's patent things that might compromise patency is blood in the airway or blood in the oral cavity, which you'll see when you pour gurgling and spitting it up. So you really want to suction. This is just basically a anchor sucker and you just want to suction. The oral cavity. Ok. Breathing might indicate often with people that have prolonged breathing, it can indicate a state of some um uh decompensation going on. So you really want to check the respiratory rate, the sacs, but be aware that you can't always attach oxygen, especially if this patient is hosing through their nose. You cannot put a mask on them. So you need to take other measures to stabilize them as best as you can. Circulation. You're thinking about how much is the circulation being compromised from the nosebleed. Um So in patients that have heavy bleeds, um IV access or even if they're feeling really quite faint IV access, take bloods. Now, obviously, you'll think about your full blood count, your coag screen grip and save, I would say, and the more heavy bleeders, you don't have to do it for everyone. But worth considering um fluid replenishment in some patients. But again, don't be too heavy on the fluids. Um unless it's not required and in some cases, it might even require a transfusion. Um You want to keep an eye on heart rate and BP, but bear in mind, they are late stages of um um a hemorrhagic shock. Um So you don't always rely on this in initial presentation. If it's really bad, then you like if they're really compromised, then, you know, you're in a bad position, so you might need more help on hand. Ok. Now I've had in disability. Now, I really only mention that because some patients um with nasal trauma, it comes in the context of a head injury. And if they're disoriented, of course, you want to do the usual screen to make sure they don't have any other trauma going on in the head. So it's just really about being a responsible doctor and taking care of other things that might not strictly be ent and an exposure, which is where you're examining the body. That's something in the context of other trauma, but it's not something you necessarily need to think about, um, in the strict setting of just a nosebleed. Ok. So examination, um, first step of examination, I always like to look in the mouth. Um, make sure that especially if the patient is actively bleeding, you want to wash your hands and protect yourself by protect yourself. I mean, you want to, um, wear a visor, um, a gown and gloves. I have had a number of occasions where patients in the middle of nose bleeds, having a nosebleed have sneezed on me or have coughed at me and you don't really want blood flying in your face. Um So when you're examining inside the mouth, you can use a tongue depressor and a light source, have a good look at the back of the oral cavity. Um, and what you're looking for really is any bleeding. So blood, you can often see dripping down the back of the mouth behind the uvula. Then you know the blood is dripping from the back of the nose that indicates a posterior bleed. Sometimes you might see a blood clot dangling from there. Not very pleasant for the patient. Not very pleasant for you. Patients will sometimes spit those out. Um and they can look like this or really long and horrible. But also when you're looking inside the mouth, you want to look at other signs that might indicate um potential cause of a bleed. Now, in this patient, I don't know if you can see she's got red spots in the tongue and on the hard palate here, this is a patient um that has her hemorrhagic telangiectasia. Now, it's not really a common thing. You won't see it, but it's actually quite nice to just be aware of this. Um If it does come a if you do come across it in practice, they sometimes have freckling of the lips as well. Ok. So the next stage of examination obviously is to look inside the nose. Now, um inside the nose, the first thing you want to do is look inside the front of the nose because like I say, that's where the majority of bleeds originate. And you can do this both in the elective and acute settings. You'll use a nasal dicum. It looks like basically, it looks like a pair of legs uh and you put it inside the nose and you can look in the front of the nasal passage. So this is a very good example, excuse me, of how to use the dicum to look inside the nose. Ok. And oftentimes you can identify bleeding points at the septum. Um sometimes they might occur laterally but mostly at the septum at the front of the nose. Then you've got nasendoscopy, nasoendoscopy, um or is something that you don't really see used in the acute setting. It's mostly in the elective setting when you can take time to examine patients largely because first of all, it's not the most comfortable thing to do. But second of all, if somebody is actually bleeding a lot, um you, you don't really get to see very much of the knees endoscope. So, um but if someone has had history of bleeds and you can't see anything from the front, then actually, this is very good at looking at the back of the nasal passage to see what is going on. So, um you might, it's actually quite good if you're doing an ent placement, it's really good to learn how to use, maybe not so much the rigid but the flexible um nas endoscope because um it's a very, very useful tool for, for practice, not just for the nose, but um it's a very good tool to learn to use treatments. Now, I'm going to mention treatment in a stepwise manner from the simplest treatment, conservative medical to surgical treatment. Ok. Now I'll start with the most conservative treatment, which is basically manual compression. It's first line and we use it for most bleeds and it generally works for anterior bleeds. But because these are the majority of bleeds, it's often very effective for, for the majority of patients. Um, and often if it's done well, you don't need to come into hospital. So what it is you do is you sit down, you lean forward, you pinch your nose firmly on the soft part of the nose and you stay like that for up to 15 minutes if you want to apply ice as by my very badly photoshopped um image here, you can apply it at the back of the neck or on the forehead to help, um, sort of, um, stop the blood vessels from um, provoking the blood vessels from bleeding any further. And that's often a very good measure for a lot of patients that stops any bleeds. Um, ask them not to swallow the blood because that can make them vomit, um, which can again worsen any worsen their fluid status. And, um, tell the patient that if this procedure or at least if this um, uh sort of practice doesn't work in about half an hour, they can come, they should come to the hospital to be seen by a medical professional, second line of treatment, um, which you can do in either the acute or the elective setting is nasal cautery. Um, nasal cautery is mostly done. Um, using silver nitrate sticks, they actually look like matchsticks and you can run it across your skin. It doesn't actually hurt you. It only starts, it only works when it's in contact with a moist surface such as inside the nose. Ok. So what you generally will do is inside the nose or the septum. Um, uh, because it's so it normally you'll use this for managing anterior bleeds. You will numb the septum with a anesthetic such as this, this is lidocaine phenylephrine um solution. And what I like to do personally is use cotton wool, dip it inside the solution and manually apply it inside the nose. You can either apply pressure or just leave it stuffed inside the nose. Give it a good five minutes just so that the area numbs and it vasoconstricts any blood vessels inside the nose. Once you're happy with that, you want to use a silver nitrate stick to burn um, any little vessels inside the nose and basically this seals them off so that it doesn't, they don't bleed again in the future after you've done this, monitor the patient because sometimes they can get a little bit of bleeding when you've done this. Um And sometimes it might meaning to go back and recauterize the area, but you don't want to be too heavy handed when you do this. Um, heavy handedness can actually lead to a septal perforation. So just be aware of that after you've done a nasal quality, you can discharge the patient home with a nose cream. And the, the common one we use is NAIN or an ointment called mupirocin. You give them this if they've got a peanut allergy because NAIN has um peanut oil in it. Ok. Treatment. Um, nasal packing lovely. So there's lots of nasal packs you can use and this is for packing the nose if someone has an anterior nose bleed. Um The common ones we use are a nasal sponge. Um These are, these are non dissolvable, by the way, these do not dissolve. Um It's a nasal sponge. It's me, this is what the measel sponge looks like. That's what it looks like, believe it or not when you put it inside the nose and this is what it swells. This is approximately what it will swell to look like if it were inside the nose and it helps to stop nosebleeds. And then you've got um nasal balloons. Um The, the Rapid Rhino is the most commonly used one and you insert this inside the nose and then once it's inside the nose, you inflate the balloon and it gives a tamponade effect. So I'll just show you this little video um for the for the nasal balloon. Hopefully you can see this CC. Ok? So that's what they do and it, it is actually quite uncomfortable for the patients. It's always good to talk them through whilst you're doing it. Um And that stays in place. The Arino actually comes in a number of sizes. 5.5 is an anterior size 7.5 fills a larger part of the nasal passage. 7.5 is the size that we commonly use. Ok. This is how one would insert it basically for each of them. You push them in along the floor of the nose with the meel. You might lubricate it a little bit before you do so, but you push it in, in a swift motion. Once it's inside the nose with the meel, you might add a few drops of water to help expand inside the nose. That's optional. But II like to do that or the Rapid Rhino as the video showed you just inflate it with some air and you keep it in place. Ok? When, if these packs are in place for more than 24 hours, you want to cover your patient with um antibiotics. Normally we use um amoxicillin or co amoxiclav and it's just so that they don't get toxic shock syndrome. Ok? Right now, this is covering posterior packs. Um And there again, I've put the Rapid Rhino here because this is the largest rapid Rhino pack they have, this is the posterior pack that they use. It's very long and it has two balloons and the two balloons inflate the front and the back of the pack, ok? Um now it's 9.5. A lot of people cannot tolerate this pack and believe it or not, if you have a very large patient, it might not even reach the back of the nasal passage. So it's worth bearing in mind. But a lot of people will like to use this if there's a posterior bleed, at least attempt to insert this inside the nose. Another way of managing posterior bleeds is a foley catheter pack. Um, with, with B dressing, I'll take my time to explain this because it's not always the easiest thing to explain, but I hope the p the pictures sorry will help. So basically, if you've got a bleed inside the nose and it's coming from the back of the nose, say you put in a pack and it only stops here. This part of the nose is completely left to bleed all the way down to the back of the throat and the patient will be uncomfortable and still be losing a lot of blood. So what you do is you put a whole catheter. Yes, that's a urinary catheter inside the patient's nose. You put it down to this level that you see here, you then inflate it and then you pull it back. So then what it does here is it blocks the back of the nasal passage. Ok. So all this area here is blocked off once you've got that in place. Um Even sorry, you've inflated the balloon and you've, you've got the nasal catheter, sorry, the, the urinary catheter, I guess it's a nasal catheter at this stage in place. You want to start packing the nose. So you pack the nose with bip, bip is a type of impregnated. Um gauze we use with antiseptic properties. If you don't have this, then a normal ribbon gauze is absolutely fine to use. Ok. And you pack the inside of the nose until it's full with the dressing. As you can imagine. This is not a very pleasant um procedure um for the patient to have done, but it's actually very effective when it's done properly. So you put in the bit dressing, you keep a pool of the catheter as you're inserting the bit pack and then once all that's in place you s you, you clamp the catheter. So the whole nasal passage here is blocked off, nothing is dripping down the back of the throat. Oh OK. I can quickly answer this one sugi. So how do you know when the, when you're right place of the catheter? You put the catheter inside and when the catheter, you actually look inside the patient's mouth and you will see the catheter dangling at the back of the patient's mouth. I know it's not very pleasant, but, and then you inflate it and you pull it forward and when you pull it forward, you'll find that you can't pull it forward anymore. That's when you know the catheter has sealed the back of the nose. Ok. And then you start packing, you don't want to pull it too hard because that will hurt the patient. But you wanna pull it enough that the pressure remains in place, pack the nose and then you clamp it. Um when you clamp it, this catheter is not going to move, this all stays in place and it allows the nasal passage to then sort of sort of tampon out itself and assist the posterior um bleed source to sort of um clot off and stop the bleed and then you can remove the catheter. Some people like to keep it in for a couple of days, ok? Um uh silver nitrate, um cause necrosis, silver nitrate can cause a se perforation. Um if you're too heavy handed with it. Um I can explain that in a bit more detail later if you'd like me to. Ok. So a quick word about dissolvable nasal packing. I didn't really address it. Now, there are two types of dissolvable nasal packing that ent me and ent are very familiar with. One is nasal pore and one is sinuso. The reason I haven't mentioned it is because we don't really use them for acute bleeds. We use them for prophylaxis ie to stop a bleed after surgery. So for example, if we're doing sort of um sinonasal surgeries such as septoplasties or sinus surgeries, we'll pack the nose with this. It's worth noting that nasal pore doesn't expand. So if you put it inside the nose, it doesn't create any tampon that effect. Ok. So that's why a lot of people do not advise it for acute nosebleeds. However, some people might use it in certain patient groups. So for example, Children that might have some small nose bleeds, you don't really want to put a rapid rhino in a child. If you can avoid it, it's not very pleasant at all. And removing it can also cause some additional trauma when you're removing the pack. So some patients, some people might opt to put a nasal pore inside the nose, sign your form. Again, not something that I've seen used in kids. And actually, I think I've only ever seen it used in an acute nosebleed maybe once or twice. This is not something that as a um sorry, an F one or an F two you will be using. This is something that if it's going to be used, it will be used under more senior discretion and might be used in patients that have heavy nose bleeds and that cannot tolerate nose packs. Ok. So, um that's why I haven't mentioned them for those of you who are familiar with these, but wonder why they hadn't been brought up treatment. Um And again, moving up the ladder of treatment, so we've addressed manual compression of the nose, um silver nitrate q nasal packing, nasal packing is really going to be uh nasal packing and, and silver nitrate co are really going to be the things that as an F one or F two, you'll be, um, you'll be doing, um, when it comes to managing nose bleeds, when it gets beyond the realm of that, then these are the surgical options which will be probably led by a consultant or a senior registrar. So, surgical treatment, um, the bipolar diathermy, this is often done, um, under, it can be done under a local anesthetic, but often is done under general anesthetic. Um for bleeds that are particularly problematic and that cannot be seen easily anteriorly, um sorry, my disconnected bipolar forceps here just to sort of highlight the fact that we want to be aiming at the sort of posterior part of the nose to cauterize any vessels in there. Now, I mentioned septoplasty and some people might say, oh, this is an odd treatment for a nose bleed. Actually, the reason I've mentioned it is because sometimes, um if you've got like a deviated septum, the bony spur, a cartilaginous spur from a deviated septum can actually cause nosebleeds. And it's something that you might cauterize in clinic um for a patient, but they might keep coming back with the nosebleeds and to definitively treat it and just get rid of the spur. So that will be um a senior L decision. And then again, you see the spur is gone, there's no encroachment of the mucosa there. Hopefully no more nosebleeds for this person here. Another one is sphenopalatine artery ligation. Um If you remember when I was talking about the anatomy of a nose bleed, the major artery that contributes to the posterior bleeds is the sphenopalatine artery. You cannot access this artery from looking inside the nose. And oftentimes the best way to do this is under general anesthesia and it's done by endoscopic approach. So you're going to go with a camera inside the nose and you actually expose the artery um by cutting into the mucosa inside the nose to expose the artery. It's not actually even an easy procedure for some consultants to do. But when it's done um in, in, in the right hand, it can be very successful um at managing any future nosebleeds. And then the last point I would like to mention um Ir that's interventional radiology or interventional radiological emboli embolization. Now we and ent do not do this. But um if we do not, if we've taken these measures and they don't work or if we cannot do these measures, sometimes we might refer to our interventional radiology colleagues. And what they do is they use a catheter which goes from the groin, often through the femoral artery all the way up into the nasal vessels at the back of the nose. And as you can see in this picture here, they use um a special dye to light up the vessels. And as you can see this patient's got a bleed here. So you can see it's sort of blushing where the source of the bleed is. So sp that's a sphenopalatine artery here, as you can see in this diagram here, and you can see this is in front just in front of it is where the bleed has come from. And what the um radiology colleagues will do is they will clip this area um or seal off this area using its particles, um special coils or a particular type of glue type of liquid to block this area. This procedure, in fact, none of these procedures are without their risks. But um oftentimes um the benefits outweigh the potential risks. Ok. So I've gone through all those points. Um I hope this has been helpful. Now, just a few um case examples that I hope will sort of give you some sort of uh so you can put this into more practical um terms first case and I've highlighted and read the, the important points. I'm sorry if it's a bit like a spoon feeding. Um So it's an 80 year old gentleman who's come into A&E with profuse leftsided, epistaxis after a fall in his garden, his nose has been bleeding for two hours and is not stopping in spite of manual pressure. So that's very good. He's tried to pinch his nose to stop the bleed and yet it's still bleeding. You can see in this picture he mentions have an irregular heartbeat that his doctor gave him medicine for. But he's very confused about this. If anyone wishes to say in the chat, um, how you would manage this gentleman, maybe I'll give about 20 seconds for anyone to write down anything and then we can go through the management together. So, maybe about 1015 seconds. Don't be shy. You might come across this scenario at some point. And then you'll remember, ah, taught me this in my um mind, the bleep lecture. Yes, Iran. Fantastic. You want to check his medication past medical history? Is there anything else be maybe before you do that, he's acutely bleeding and it's profuse. Is there anything that you want to be? Or Rebecca consult with him? Um That's actually very good anticoagulant reversal. Packing? Fantastic. Yes. You want to consider packing measure BP. So you actually uh yeah, it, it, yes, it says ABCD. E. That was the first thing I wanted to hear. That's wonderful. Group and safe. Yep. Yep. Yep. All correct answers. All correct answers. Fantastic. Um ok. So management ABC gold star to you. Y Shah. That was the first thing really. I wanted to make sure that was in front of your mind. You really wanna stabilize this gentleman check and correct any vital instability. So for him, he's actively bleeding. He mentions being on a medication for irregular heartbeat. So you do in the back of your mind, you're thinking is he anticoagulated if you want to correct that, correct any vitals that might be out of whack. Um, now he had a fall. Um, it might not be something you do immediately, but you might want to also consider a CT head because he's a bit confused as well. We don't know if this confusion is age or if it's due to the fall, examine, oral examination, anterior anoscopy. Very unlikely you're going to do a scope with a flexible or rigid knees, endosc nasendoscope. In this setting treatment, the most likely treatment you're going to do for a patient like this is a nasal pack because when people fall and hit their face or hit their nose, there's not going to be a discrete need. Um, bleeding point inside the nose oftentimes the inside of the nose has undergone what you call a shearing injury. So you'll find it's a bit of a bloody mess. So the best thing to do with pa patients like this that have a profuse bleed after a fall just pack their nose for me. I would put in a rapid rhino nine times out of 10. That does the trick. If it doesn't do the trick, you can consider a foley catheter. Um I would advise doing this with senior guidance the first time you ever do it because it's not easy to do correctly. But that might be something people might consider. And then, and if he needs to keep the pack in um a non dissolvable pack. You'll, you'll generally have to admit these patients and cover them with antibiotics. So he doesn't get toxic shock syndrome. Ok. A second example, you've got a 12 year old girl. She comes to your clinic with her mom on a hot July day. A bit of a far since we've not had many hot days in July. Um, mom says her daughter started getting frequent nosebleeds and she sneezes a lot when she visits the park. You notice her daughter has eczema on the flexor surfaces of her elbows. How will you manage this patient chat? Tell me, what do I do with this girl? I have no clue. I'm fresh out of medical school. She's just dropped in my clinic. Tell me in the chat. What I do, please. I'll give you 1520 seconds. Come on. I need some help. I don't know what to do. Mum's looking at me. She's, uh, you know, she's look, she's tutting. She's like, oh my God, this doctor doesn't know what to do. Ah, fantastic. Thank you, Rebecca history. Yes. Triggers family history. How they normally manage nosebleeds. Fantastic answers. All very, very useful. Um Anything else? Anything else, Rebecca, if you're seeing triggers, what kind of triggers if you can just maybe put one or two? Any that cross your mind? Yeah. Or anyone else? I don't wanna put Rebecca on the spot. She's been doing super well. Time of year. Eg Paulen, a gold star to you Rebecca? That's phenomenal. Ok. Fantastic. New pets. Do you know what? That's a really, really good answer. A lot of people don't think about that. There are any animals in the home Aspirin A and I think I know where you're going with this question and I'll, I've got to say I'm gonna give you a very big nod for that. That's really, really good. I really like that. Um, ok. Um, I imagine you're probably thinking about Samter um triad slightly beyond the scope of um F one F two. But if that's the thinking you're making, I'm very, very impressed. OK. Management. So ABC is not immediately necessary. I'm just gonna get that out of the way because she's walked into your clinic. She's not actively bleeding, she's otherwise quite fine and stable. You can take a history, take your time, examine her. No big deal. Look inside. If I mouth oral exam, probably not really necessary, I'll just put it in there for some reason. Anteriores copy. Yes. So you want to look inside of the nose. Do you see any bleeding points? The treatment that you might be considering for a girl like this most likely is going to be nasal qry? Ok. Sorry, I actually should have gone back some of the points here. So 12 years old, she's young hot July Day. So you want to think about heat is heat, a potential trigger for the nosebleeds because they've only started the nosebleeds and they're frequent and she says it's a lot. So, is a heat contributing factor or is it the fact that she's in a park around lots of nice flowers and plants that are causing her to blow her nose? You also notice she's got eczema. So you're thinking about any atyp? Ok. Um, and um, I think Adam kind of touched on that, um with the fact of the aspirin allergy, which I think is very good. So normally with these kind of patients, you'll, you'll often do nasal cry because they might have a small bleeding point inside the nose. It's exacerbated with hot weather or sneezing. Um, so you can cauterize the nose and then send them home with an ointment or cream. Now, ABC, not immediately necessary but say you cauterize this girl in the clinic and all of a sudden her nose starts bleeding and then she starts getting faint and then she collapses, you'll do your ABC S. Ok. So like I say, it's not just confined to patients that come in A&E occasionally in clinic, this might be necessary. Now for a patient like this, you want to be aware of um, imparting good first aid advice, pinching the nose and such when they're at home to help manage nosebleeds. A lot of people actually don't get that first aid advice correct. So sometimes it helps to just go through showing them how to do it. Then the additional considerations that some of you lovely people mentioned in the comments, um treat for hay fever or consider hay fever allergies and she's got, she's got eczema. So you want to think about actually atopic and you wanna do allergy testing and of course, the today will include things like pets, sensitivities and such. Ok. So the learning objectives which I hope have gone through um is the anatomy of the nose. Uh Well, I say the anatomy of the nose, basically the vascular, the relevant vascular anatomy with regards to nosebleeds, um causes that you want to be aware of the history and the points that you want to address clinical. Uh Oh Actually, I think I've got that down twice. Sorry about that stabilization, which is ma mainly the ABCD ease and examination of the nose and treatment of the nose. So I hope that sort of rounds everything and that the clinical scenario sort of tied everything together for you and that's it. Thank you very, very, very much for um watching my presentation. I will come off my platform now. Thank you. Thank you. Thank you so much Aku for such a wonderful presentation. I very thorough, very extensive, very thorough, very extensive. I think you answered all the questions that people have in, in their mind. That is the reason that I only see uh 23 questions. Uh I think I think there are a few questions uh for you in the questions and answers section. If you want to address those? Lovely. So, Shama asked me a question. Um, hi, Shama, what drugs can commonly cause nasal bleeding? So, you want to think about medications um, or blood thinners which generally fall in two classes. You've got your antiplatelets and um your anticoagulants. So, medications such as Warfarin, which not many people use nowadays, but um but can cause um or sorry, exacerbate, mostly exacerbate nosebleeds and your dox, which are your new range of um anticoagulants like Rivaroxaban and the big um those medications. Um uh And you can also do stands for direct oral anticoagulants. Basically, they're the new new breed of um blood blood thinners and then of course, antiplatelets such as clopidogrel and aspirin. Aspirin's not as big of a problem. But um the other ones are, um and some, some of these drugs you might want to consider stopping. Um Really, it depends on the half life of the medication. So, um patients that have very heavy nose bleeds, if they're on Warfarin, you want to check the inr. If they've got an inr of like say six or seven, you might want to give them Vitamin K to sort of reverse it. Um If they're on a medication like um aspirin, often you can continue that. And do they have a short half life? So you can generally stop those um such as Rivaroxaban to help you manage a heavy nose bleed. Um Yeah, so, so basically, uh these are the ones that you just want to be aware of. Is that helpful shama? So I kinda went off. Um. Right. Ok. And then there's Sugi. Yeah. So, Sugi, I believe I did answer part of your question. Um, when I went through the, um, the nasal, the catheter for the foley, sorry, the foley catheter for the nose, you basically advance the catheter and least until you see it in the back of the mouth, inflate it with sterile water and then pull it forward. So then the balloon is actually resting at the very back of the nasal passage. When you pull it forward, it, it won't move any further forward. Ok. No, pull it really hard, just enough that you feel some tension and then you pack the nose. Um, now that catheter can cause necrosis. If you're not careful, if you're applying too much pressure, it can actually affect the back of the nasal passage. And also if you, um, apply a lot of tight pressure at the front of the nose, you can cause necrosis of the front of the nerves of the nose. That's why you put a little bit of um, cotton gauze and then you clamp it. So then the pack, the, the catheter doesn't move, but also the patient is relatively comfortable and the silver nitrate. Yes, just cauterize the vessel gently. Don't be going through 20 cautery sticks. You'll end up perforating the patient's um, nasal septum, which can cause nosebleeds Ok, so I hope that was helpful. Um Rebecca for the second example, case of the 12 year old child, would you usually screen for leukemia or hemophilia as well? Um, in a clinic setting? Um So if you think about the presentation I gave it's, she's had freq recent and frequent nosebleeds. Um normally, you know, it's not really the first thing on your mind when you think about these kinds of patients, the, the general saying is common, things are common. So you're thinking about the fact that it's happened during the summertime, we know it's very hot that she's, it's triggered when she's around flowers and grass. So you're going to obviously think about things like the heat and um and pollen sensitivities. You might not automatically think about leukemia or hemophilia things that might clue you into that will be other aspects of the past medical history. Are they bruising all the time? Are they bleeding from other places when they cut themselves? Are they profusely bleeding? And it doesn't caught? And in those patients? And also if there's a family history, then it might clue you into something else going on. And in those cases, then you might want to include a screen to um do a coagulation screen which will often flag up or sorry, a full blood count and a coagulation screen which will often flag up if further investigation is necessary. I hope that's helpful. Sorry, I didn't get you clear on the causes of toxic shock syndrome. So, toxic shock syndrome is really not common. Um uh to be honest with you really, when you've got blood and stasis inside of a cavity and it's, it's it can become a breathing ground for infection. So, and it might sound a bit gross. A lot of women are very much aware of this because when women menstruate and they use tampons a lot of the times they're cautioned about toxic shock syndrome because if you leave it in place for a long time, then the risk of infection can cause you to have this basically septic reaction. It's a similar idea in the nose as well. It's basically a nasal tampon and if you keep it in place for a long time, um the blood can become, or at least the old blood can become infected, the patient can get toxic shock syndrome. So that's why when you pack the nose for more than a couple of days, um you want to cover them with antibiotics so they don't get this nasty, um, nasty infection. Is there any other questions? I'm looking in the Q and A can't see anything else. Fantastic. I think, I think that's all. I think that, that, that are all the questions that we had. Oh OK. Thank you so much Aku for such an extensive presentation on Epistaxis. I mean, I have been working with you for a very long time. I myself have learned a lot of new things today and I believe everyone has, which obviously we will be incorporating in our clinical practice from now on. But thank you so much for, for uh, the, the, the extensive presentation. You're very welcome. Yeah. And for the, for the surgery and feedback, obviously, I will be, uh, you, you might have received the, uh, email for your, uh, certificates. You, you provide the feedback and the certificates will be available. But I have relieved released the feedback form in the chat anyways for you people to just uh give the feedback and then get your certificates from there. And again, thank you so much, everyone for joining in for believing content and our speakers. Thank you so much for that. Um II mean, I understand that we have gone slightly over time today, but I think that is only because the content was very good. Um So, so thank you so much. A again. Thank you. Thanks everyone for coming. Do I just send you the slides then or can you? Yeah, so just send me the slides in and I will be putting it on the platform and um all the attendees will be able to download it from from there. Awesome. Thank you so much. Take care everyone. No problem. Thank you. Thank you. Bye bye. All right, everyone. Have a lovely uh evening and we will see you in the next session which obviously we will advertise in, in, in a short period of time. Ok. Have a, have a lovely evening. Bye bye.