I once had a friend who could make his nose bleed just by tapping it… very useful for getting out of PE! Enjoy this MCQ set on epistaxis and nasal conditions!
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Stem 1, question 1 of 4
You are a Fy1 in A&E and you've just started your shift. 20 minutes in at 8.25, a 26 year old female presents after waking up to a blood stained pillow. She has been driven in by her boyfriend. Her nose appears to still be bleeding from her right nostril.Which of the following would be your first concern?
Her pain level
Her blood pressure
Her risk of airway obstruction
Her current GCS
Question 1 Explanation:
We should always assess our patients using the ABCDE approach; airways, breathing, circulation, disability and everything else. Starting with airway, we want to make sure her airway isn't compromised before we even begin to think about her pain level, GCS and temperature.
Stem 1, question 2 of 4
You remember that for anterior bleeds, Kiesselbach's plexus is the most common source of bleeding.Which of the following arteries does not contribute to Kiesselbach's plexus?
Greater palatine artery
Septal branch of the superior labial artery
Lesser palatine artery
Anterior ethmoidal artery
Question 2 Explanation:
There are 4/5 arteries that make up the Kiesselbach plexus, these are: Anterior ethmoidal artery (branch of the ophthalmic artery) Sphenopalatine artery (terminal branch of the maxillary artery) Greater palatine artery (from the maxillary artery) Septal branch of the superior labial artery (from the facial artery) Posterior ethmoidal artery (branch of the ophthalmic artery) (This one is a little contentious, as it actually supplies the septum) To remember the vessels that form the Kiesselbach plexus, think of LEGS: Labial (superior), Ethmoidal (anterior), Greater palatine, and Sphenopalatine arteries. The lesser palatine artery supplies the soft palate as well as giving off tonsillary branches to the palatine tonsils.
Stem 1, question 3 of 4
Effective first aid is able to stop ~90% of nose bleeds.Which of the following best describes how to manage simple nosebleeds?
Sit forwards so blood doesn't drip back into the stomach. Apply pressure by pinching the anterior aspect of the nose, avoiding the nasal bones. Do this for 15-20 minutes.
Sit forwards so blood doesn't drip back into the stomach. Apply pressure by pinching the anterior aspect of the nose, pinching specifically over the nasal bones. Do this for 5 minutes.
Sit backwards to limit blood dripping out of the nose, aiding clotting. Pinch the anterior aspect of the nose over the nasal bones. Do this for 15-20 minutes.
Sit backwards to limit blood dripping out of the nose, aiding clotting. Pinch the anterior aspect of the nose. Do this for 10 minutes, then sit forwards for 10 minutes.
Pinch the anterior aspect of the nose and place an ice pack to the nape of the neck, initiating vasoconstriction in the nasal mucosa.
Question 3 Explanation:
The best answer is answer 1. Blood can irritate the stomach and so sitting forwards is be advised. Pinching should avoid the nasal bones, and should push the nasal ala against the septum. 15-20 minutes should be enough to stop the bleeding. Some authors advocate placing ice pack to the nape of the neck with belief it produces a reflex vasoconstriction in the nasal mucosa; however there is little research or evidence to support this.
Stem 1, question 4 of 4
Simple first aid measures are ineffective at stopping the bleeding in this patient. On examination, you think you can see the site of bleeding- it looks like a small red dot, but you can't quite tell how far it extends.What is your next step?
Nasal packing with a Folley catheter.
Nasal packing with a rapid rhino.
Further examination under anaesthesia.
Nasal cautery with silver nitrate, both nostrils.
Nasal cautery with silver nitrate, only the affected nostril.
Question 4 Explanation:
As you can identify the site of bleeding, cautery is the best option. You should only cauterise one side of the septum to avoid nasal septal perforation. You would consider nasal packing if nasal cautery has been ineffective or the bleeding point cannot be seen. A Foley catheter is used for posterior epistaxis.
Stem 2, question 1 of 5
A 86 year old female presents to A&E with a 12 hour history of epistaxis. She is breathless and very unhappy. She said that pinching her nose hasn't worked and she's subsequently swallowed lots of blood. She is on long term anticoagulation therapy but has not bothered attending her anti-coagulation appointments for the last few months as she feels well in herself. She is tachycardic with a pulse of 121bpm regular and blood pressure 82/64mmH.After fluid resuscitation, what investigations would you order?
An ECG, chest Xray and ABG. Then a coagulation screen.
Bloods for FBC, U&Es, clotting screen and crossmatch. An ECG and ABG.
An ECG, D dimer and ECG
Bloods for FBC, U&Es, clotting screen and crossmatch. A chest X ray
Troponin levels and an ECG
Question 5 Explanation:
A full blood count, U&E and clotting screen are all helpful because she has been bleeding for so long. A cross match is necessary incase she needs transfusing. The patient is tachycardic so you want an ECG to assess rate and rhythm. As she has been bleeding for over 10 hours, an ABG is needed to check the acid base status of the patient and then treat any abnormalities. D dimers and Troponin levels aren't necessary for this patient, neither is an X ray.
Stem 2, question 2 of 5
In your history taking, you find out the patient takes Warfarin. Her INR is 12.Based on this results, how would you further manage the patient?
Reduce the warfarin dose and check again in an hour.
Administer vitamin K and prothrombin complex.
Stop warfarin completely.
Reduce the warfarin dose and administer vitamin K.
Stop warfarin, administer vitamin K and prothrombin complex concentrate.
Question 6 Explanation:
As her INR is very high and she is bleeding, warfarin needs to be stopped. Then its effects need to be reversed with vitamin K and prothrombin complex concentrate.
Stem 2, question 3 of 5You suspect that her epistaxis is due to over anti-coagulation. Which of the following aren't common causes of epistaxis?
Question 7 Explanation:
Anaemia isn't actually a predisposing factor for epistaxis, however all of the other conditions can lead to epistaxis.
Stem 2, question 4 of 5
After being stabilised, you talk to the patient about the importance of monitoring anticoagulation. She agrees this is with taking seriously. But she says she doesn't like being on warfarin because it has so many interactions.Which of the following doesn't interact with warfarin?
Question 8 Explanation:
Warfarin interacts with lots of drugs. If prescribing a drug that may interact, make sure to check the person’s INR 3–5 days after starting treatment with the new drug.
Stem 2, question 5 of 5What would be the best management for this patient as you discharge them?
Restart warfarin and continue with vitamin K.
Arrange anticoagulation follow up and continue with vitamin K.
Arrange anticoagulation follow up and re-start warfarin at a lower dose.
Arrange anticoagulation follow up and re-start warfarin at the same dose.
Arrange anticoagulation follow up and omit warfarin until her appointment.
Question 9 Explanation:
Warfarin should be restarted a lower dose, no more vitamin K needs to be given. She should have an appointment in the anticoagulation clinic because it might be better for her to change to a NOACs (Apixaban, Rivaroxaban or Dabigatran).
Which is the least likely complication of epistaxis?
Possibility of airway obstruction
Septal hematoma or abscess
Question 10 Explanation:
Anosmia is usually a postoperative complication, so is the least likely. All of the others as risks after epistaxis, so worth safety netting for with the patient.
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