Episode 14: ENT Emergencies Part 1

Author: Eoghan Colgan    @eoghan_colgan
Special Guest: Gerry McGarry

30/05/18


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Guest Bios

Gerry McGarry

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Gerry McGarry is a Consultant Surgeon in ENT in Glasgow with specialist interests in Head and Neck Surgery, Rhinology and Endoscopic Skull Base Surgery.  Gerry specialises in advanced endoscopic surgical techniques for treating sinonasal tumours.  Active in postgraduate surgical education he is on the faculty of many courses in the UK and abroad including his “Advanced Endoscopic Sinus Surgery” Course in the Royal College of Surgeons of Edinburgh.  

 

Gerry previously acted as Convener of Education and Wade Professor of Surgical Studies in The Royal College of Surgeons of Edinburgh. He is Honorary Clinical Senior Lecturer in Otolaryngology in The University of Glasgow.


Show Notes

This is part one of a three-part series on ENT emergencies. In this episode Eoghan and Gerry primarily discuss the ED management of epistaxis. Do you apply cotton wool after silver nitrate? Have you heard of thrombin gelatin foam for light secondary epistaxis? That plus a whole lot more..


Take Home Points

REPEAIRING CSF LEAKS

  • Increasingly done through transnasal endoscopic approach
    • Good success rate and much reduced morbidity
    • Refer CSF leaks to an endoscopic ENT surgeon if available

EPISTAXIS

  1. ABC resuscitation
    • Secondary causes (INR/platelets) may need treated to facilitate the following to work
  2. Hippocratic technique: sit up, breathe through mouth, pinch soft part of nose for 10 uninterrupted minutes
  3. Vasoconstrictor-soaked cotton ball placed in nose and step 2 repeated
    • Co-Phenylcaine a good choice
    • Other options include oxymetazoline, otrivine spray, ephedrine spray
  4. Silver Nitrate – only good for slower bleeding
    • Attach cotton wool to other end of silver nitrate stick
    • Press silver nitrate on top of bleeding point and slightly around it for a few seconds
    • Then use cotton wool to press on the area for a few seconds
      • This forces silver nitrate into mucosa and completes the burn (appears black afterwards)
  5. Thrombin Gelatin Foam e.g. Floseal
    • Useful consideration for secondary bleeds that are still trickling, before a tampon (which are abrasive and can promote further bleeding)
  6. Tampons preferred over balloon products
    • Place them dry and with care along floor of nasal cavity (not up)
    • Use co-phenylcaine spray before application (anaesthetizes and constricts mucosa which facilitates passage)
  7. Naseptin cream – 2-3 applications per day for one week
    • Useful discharge med for those that have been cauterized (avoid infection in burned skin)
    • Many be a reasonable choice for those with recurrent small bleeds that had no intervention given
  8. “Posterior” Nose Bleeds
    • These are more often simply heavy anterior bleeds
    • ABC resus and reverse secondary causes as appropriate
    • Tampons and transfer
    • Urinary catheters are seldom required but if used they simply prevent blood flowing into pharynx and will require anterior tampon concurrently


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