Required instruments [Figure 72]
• Bayonet forceps
• Nasal speculum
• Head lamp
• Tampon (Merocel®)
• Kidney dish
• Trichloroacetic acid [Figure 73]
• Surgical cotton applicator and cotton wadding [Figure 73]
Figure 72
Figure 73
Procedures
There are also various methods for stopping a nose bleed. Your choice of a specific method will not only depend on the availability of the materials, but also on the nature, location and severity of the bleed. It is recommended to locate the source of the bleed first, by means of anterior rhinoscopy, before stopping the bleed.
By squeezing the nose
- This technique is effective for a frontal nose bleed from the Kiesselbach plexus. This type of bleeds is characterised by a constant flow of dark red blood.
- Ask the patient to blow the nose to remove any clots (these may prevent the blood flow from being stemmed) and to bend forward slightly.
- Provide a kidney dish to collect the blood that flows out of the nose.
- Grasp the nose, directly below the bony nasal skeleton, between the thumb and index finger and firmly squeeze the nose shut [Figure 74]. This has to be maintained for approximately ten minutes.
Figure 74
Through nasal packing
If you are not capable of stemming a frontal nose bleed by squeezing the nose shut, or the bleed is very heavy, the source of the bleed is further back in the nose, or it is an arterial bleed (characterised by the spurting flow of bright red blood), insertion of a nasal tampon is indicated.
The tampon consists of spongy material that expands rapidly as soon as it comes into contact with liquid.
- The patient sits on a chair with good back support and provide a kidney dish to collect the blood. Sit on a height-adjustable stool beside or in front of the patient. Your eyes should be at the same height as the patient’s nose. Make sure that all required materials are ready for use.
- Ask the patient to blow their nose.
- Put on the head lamp and aim the light onto the nose of the patient. Press the tip of the nose slightly upwards with your thumb and, with a nasal speculum, widen the nostril from which the blood is flowing [Figure 75]. Hold the speculum with your non-dominant hand. The light of the head lamp now should now shine into the nose.
Figure 75
- With you dominant hand, use the bayonet forceps to pick up a tampon
[Figure 76] and insert this as high as possible into the nasal cavity of the patient whilst looking through the nasal speculum [Figure 77].
Figure 76
Figure 77
- Following insertion, dampen the tampon with xylometazoline spray 0.1%. This will not only accelerate expansion of the tampon, but will also cause vasoconstriction [Figure 78].
Figure 78
After 3 to 4 days you can carefully remove the tampon.
- Before doing this, make the tampon wet using some water or physiological salt solution.
- Widen the nostrils with a nasal speculum and illuminate the work area with a head lamp.
- You can remove the tampon with bayonet tweezers or forceps.
Through cauterisation
If a bleed cannot be stemmed by a nasal pack either, the next step is to cauterise the site of the bleed (closure of the wound through burning). This can be done chemically, using trichloroacetic acid, or electrically. Only the chemical cauterisation method will be covered in this program.
- Locate the exact site of the bleed (see chapter 3) by anterior rhinoscopy. In this case, use the otoscope with a 6 mm speculum attached. Dampen the cotton wadding with trichloroacetic acid.
- Carefully dab around the source of the bleed with the cotton wadding and briefly dab the centre of the area [Figure 79].
Figure 79
This should be done very carefully; trichloroacetic acid is very corrosive!