Acute Epistaxis

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Question 1 of 10

1. Question
Which one of the following statements, regarding the context and epidemiology of epistaxis, is correct?
- Most members of the public have a clear understanding of the first aid management of epistaxis
- Studies have shown that, in general, epistaxis is well managed in emergency departments (ED) in the UK
- With an appropriate protocol in place, 85 % of epistaxis patients can be safely managed in the ED without admission
- 75% of all epistaxes arise from the anterior nasal cavity
- Epistaxis accounts for approximately one in every 1000 ED presentations
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Question 2 of 10

2. Question
Concerning the pathophysiology of epistaxis, which one of the following statements is correct?
- Most cases of epistaxis present to the ED in the summer months
- Staphylococcal colonisation of the anterior nose is thought to be an important factor causing nosebleeds in children
- Kiesselbach’s plexus is an anastamosis formed from branches of the internal carotid and vertebral arteries
- The high concentration of blood vessels on the anterior nasal septum is an embryological remnant and serves no physiological purpose
- A clear cause-effect relationship has been demonstrated between hypertension and epistaxis
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Question 3 of 10

3. Question
A 46-year-old man presents with an epistaxis of 1 hour duration. His nose is still bleeding on arrival in the ED. Which one of the following statements, regarding first aid management of the patient, is correct?
- The patient should pinch the bridge of the nose, thereby compressing the vessels against the nasal bones
- Application of ice to the neck and forehead will reduce nasal blood flow and therefore the severity of bleeding
- Encourage the patient to lean backwards as blood can then be spat out into a receiving bowl and its quantity more accurately measured
- If the patient is uncompliant, a swimmer’s nose clip can be used to control bleeding from the nose
- Resuscitation must wait until first aid measures have been used to stop bleeding
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Question 4 of 10

4. Question
Whilst you are waiting for first aid measures to work in your patient, you start the process of taking a history, performing an examination and organising investigations. With regard to this process, which one of the following statements is correct?
- A history of cocaine use is not important
- It is possible to accurately estimate the quantity of blood loss from the spillage seen on towels and tissues
- A heavy alcohol binge in the last 24 hours is associated with an increased risk of epistaxis
- Other than measurement of cardiorespiratory parameters, little is to be gained from a general examination of the patient
- Routine coagulation studies are needed in every patient to exclude an underlying undiagnosed coagulopathy
Correct

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Question 5 of 10

5. Question
First aid measures have failed to control the epistaxis in your patient. Prior to an examination of the patient’s nose you consider personal protection against blood contamination. Which one of the following statements is correct regarding personal protective equipment?
- The risk of blood contamination from a patient with an epistaxis is no greater than for any other condition
- Wearing gloves is sufficient, as blood spread beyond gloves is rare when treating epistaxis
- Practitioner ocular blood contamination has been found to occur in less than 1 % of cases
- As epistaxis affects mainly the young and old, the risk of acquiring a blood borne virus makes the use of personal protective equipment unnecessary
- Putting a facemask over the patient’s mouth may help to reduce blood contamination of the practitioner
Correct

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Question 6 of 10

6. Question
In order to examine your patient’s nose, you start to gather the equipment you will need. Which one of the following statements is correct?
- Most UK EDs lack the necessary facilities and equipment for the management of epistaxis
- A rigid Yankauer-type catheter is the best way to apply suction to the nasal cavity
- Either a silver nitrate tipped applicator or hot-wire electrocautery may be used, although electrocautery is more effective
- Lidocaine will both anaesthetise and vasoconstrict the septal blood vessels
- A nasal speculum is unnecessary as Little’s area is so anterior and can be easily seen
Correct

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Question 7 of 10

7. Question
On visualising the anterior nasal cavity of your patient, you identify an area of bleeding on the anterior nasal septum. Which one of the following statements regarding cautery of the nose are correct?
- The area surrounding the bleeding vessel can be cauterised if bleeding is brisk and direct cautery is unsuccessful
- Both sides of the nasal septum can be cauterised in the same treatment, as the presence of bilateral bleeding indicates a good blood supply to the cartilage
- When using silver nitrate, the applicator can be applied to the septum for up to 60 seconds in one spot
- Sodium bicarbonate can be used to neutralise excess silver nitrate to avoid staining and inadvertent burns
- If attempts at cautery are unsuccessful, the patient should be referred to the on-call specialist team
Correct

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Question 8 of 10

8. Question
A 5-year-old attends the ED with a nosebleed. By the time he is seen, his nosebleed has stopped with first aid measures. His parents say they are worried as he has had a number of nosebleeds recently. There is no history of foreign body insertion.

On examination, you see a localised area of inflammation and crusting, which is not currently bleeding, to the anterior part of the septal mucosa on the left side. Which statement is correct regarding the management of this child?
- Coagulation studies must be routinely performed in children with recurrent nosebleeds
- Application of topical antiseptic cream to the inflamed area is as effective as silver nitrate cautery in preventing recurrent nosebleeds
- Crusting of the nasal mucosa is common and thought to be due to repeated upper respiratory tract viral infections
- The lack of a relevant history excludes a foreign body as a cause of the nosebleeds
- Silver nitrate cautery is the best and least painful treatment for this child
Correct

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Question 9 of 10

9. Question
A 67-year-old woman presents to the ED with epistaxis from her right nostril for the last 3 hours. Both first aid measures and attempts at cautery have been unsuccessful. You make a decision to pack the nose with an anterior nasal pack. Which one of the following statements is correct?
- When compared to traditional packing with ribbon gauze and BIPP, a compressed sponge tampon (e.g. Merocel) is equally effective in stopping bleeding
- No further action is needed if the bleeding appears to stop immediately after the pack is inserted
- The compressed sponge tampon (e.g. Merocel) and the inflatable balloon tampon (e.g. Rapid Rhino) are equally comfortable and easy to insert and remove
- Continuing bleeding following insertion of an anterior pack, should be managed with its removal and further attempts made with a different type of pack
- If bleeding is not controlled with an anterior pack, passage of foley catheters into the nose is the next technique that must be tried
Correct

Incorrect
Question 10 of 10

10. Question
A 72-year-old man with epistaxis is managed with an anterior pack as both first aid measures and attempts at cautery failed to stop the bleeding. You contemplate sending the patient home. Which of the following statements is correct with regard to this decision?
- All patients with an anterior nasal pack should be admitted due to the risks of airway obstruction and infection
- All patients with an anterior pack in situ should be seen by the Otolaryngology team prior to their discharge
- An Otolaryngologist must reassess the patient and remove the pack within 48 hours
- It is safe to send the patient home if he is taking warfarin, as long as his INR is checked
- All patients with an anterior pack should routinely be started on antibiotics
Correct

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