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Kiesselbach's plexus = Little's area
位於鼻中膈前方軟骨區 anterior nasal septum
是最常見鼻出血位置 (90%)
Superior labial branch of the facial artery +
Anterior ethmoidal + terminal branch of the sphenopalatine artery
Posterior bleeds is the sphenopalatine artery
which is a terminal division of the internal maxillary artery
Clinical features suggestive of a posterior source :
- Elderly patients with either inherited or acquired coagulopathy
- Significant amount of hemorrhage visible in the posterior nasopharynx
- Hemorrhage from bilateral nares
- Epistaxis uncontrolled with either anterior rhinoscopy or an anterior pack
出血點若在中鼻甲以上 : 源自內頸動脈
中鼻甲以下 : 外頸動脈
- 局部 : 挖鼻, 擤鼻涕, 打噴嚏, 異物, 骨折
醫源性, 氣候乾燥, 化學物質 ( Cocaine, nasal sprays )
鼻部腫瘤, 局部發炎
- 系統性 : 凝血功能, 肝功能, 尿毒症, Anti coagulant,
HTN, SLE, Wegner
- CBC, PT, aPTT, X ray, CT
- Airway, Breathing, Circulation, 評估 Blood loss, shock sign
坐姿頭前傾, 局部壓迫以手指捏住鼻軟骨 繼續加壓20分鐘
鼻腔前面出血可用浸泡鼻血管收縮劑的棉球或紗布填塞
Nasal speculum 垂直撐開
例如用 4%cocaine solution或 oxymetazoline或phenylephrine solution
如果出血需要更積極治療時，宜使用局部麻醉劑如４％cocaine solution或 tetracaine 或 lidocaine 溶液
進行治療步驟前應給予適當的麻醉。
topical vasoconstrictors and anesthetics
(combination of lidocaine or ponticaine with phenylephrine or oxymetazoline spray)
and topical moisturizing ointments can be of value.
- 第二線 : Cemical (silver nitrate) or electrical cautery is sometimes necessary
只是不能兩側鼻中膈都燒, 會穿孔
If two attempts at direct pressure have failed, chemical cauterization
with silver nitrate is the next appropriate step for mild bleeding
- 第三線 : Anterior packing -> Posterior packing
- 第四線 : 動脈結紮
ENT OPD follow up within 48 to 72 hours for removal of nonbiodegradable packing
more than 48 hours, an antibiotic with staphylococcal coverage
such as amoxicillin-clavulanic acid has been traditionally recommended for Toxic shock syndrome
不過抗生素 benefit 未知
如果 24 -36 小時就會移除則不需要 routine anti
Nasal bone fx : 止血, 冰敷, X ray 確認
一般觀察三天局部消腫後再回 OPD 排手術
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