3. epistaxis
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O l e h :SIGIT SASONGKO
DEPARTEMEN THTRUMKIT TK. II DUSTIRA CIMAHI
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RIWAYAT HIDUP SINGKAT
Nama : Sigit Sasongko, dr, MKes, SpTHT
Tempat/Tgl. lahir : Probolinggo, 7 Januari 1966
Pangkat : Letnan Kolonel CKM
Jabatan akademik : Lektor
Jabatan struktural : Ka. Lab/KSM I.K. THT FK Unjani/RS Dustira
Riwayat pendidikan :
S-1 FK Unair Surabaya, 1990
S-2 dan Sp-1 FK Unpad Bandung, 2003
Riwayat pekerjaan : Anggota PERHATI Jabar, 2006sekarang.
Ka. Lab/KSM I.K. THT FK Unjani/RS Dustira, 2007sekarang
Dosen LB PPDS I I.K. THT FK Unpad, 2008 - sekarang
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Anatomi Hidung dan SPN
Hidung Luar :Bentuk piramidBagian-bagian :
Puncak hidung (apex N)Dorsum nasiPangkal hidung (bridge)
KolumelaAla nasiNares anterior
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PerdarahanAtasR.Hd.: a.karotis interna a. oftalmikus
a ethmoid anterior dan posteriorBawahR Hd : cabang a maksilaris internaa sfenopalatinadan ujung a palatina mayor
DepanR.Hd.: cabang fasialisDepan septum: Plexus Kieselbach(Littles area)
Anastomosis dari : a. Ethmoid anterior
a. Sfenopalatina dana. Palatina mayora. Labialis superior
Letaknya superfisial, mudah cedera
Sumber epistaksis terbanyak
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A : a. meningeal anterior
B : a. etmoidal anterior
C : a. etmoidal posteriorD : a. nasal lat. posterior
E : a. spenopalatina
F : a. palatina mayor & minor
Arteri pada dinding lateral hidung
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A : a. etmoidal anterior
B : a. etmoidal posterior
C : a. septal nasal posteriorD : anastomosis dengan
a. palatina mayor
Arteri pada septum nasi
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ANATOMI VASKULARISASI HIDUNG
BERASAL DARI CABANG A. KAROTIS
INTERNA DAN A. KAROTIS EKSTERNA
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EpistaksisMungkin 90% dapat berhenti spontan (penekananhidung). Epistaksis berat perlu tindakan
Etiologi :
1. Sebab lokal :a. trauma:
Beringus keras, bersin keras, rudapaksa, iritasi gas
b. Infeksi hidung/sinus paranasalc. Neoplasma: hemangioma, karsinoma, angiofibromad. Kelainan kongenital
Oslers diseases (hereditary hemorrhargicteleangiectasis)
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2. Sebab-sebab sistemik epistaksis:
a. Penyakit kardiovaskularhipertensi, arteriosklerosis, nefritiskronik, sirosis Hp., sifilis, DM.
b. Kelainan darahtrombositopeni, hemofilia, leukemia
c. Infeksi:DHF, tifoid, morbili, influenza
d. Perubahan tekanan atmosfirCaisson diseases
e. Gangguan endokrin
kehamilan, menopause
Etiologi Epistaksis :
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Sumber Perdarahan epistaksis :
Dua sumber utama :1. Bagian anterior
Pleksus Kiesselbach
a. etmoidalis anteriorterbanyak dan tidak hebat
2. Bagian posteriora. sfenopalatinaa. etmoidalis posteriorLebih jarang, tetapi hebat
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Terapi Epistaksis:
Tiga prinsip :
1. Hentikan perdarahan
2.Cegah komplikasi
3.Cegah rekurensi
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PHYSICAL
EXAMINATION
General status
Local status
Determine :- Anterior or posterior
- Right or left cavum
nasi
- Duration of bleeding
- Quantity of blood loss
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MANAGEMENT
BASIC CARE OF HEMORRHAGE1. Vital signs
2. Hemoglobin and hematocrit
3. Fluid resuscitation & blood transfusion4. Central venous pressure
Uncommon, but the condition is life-threatening:
Exsanguinating epistaxis
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Predisposition factors :
severe midfacial trauma with maxillary artery
laceration, often associated with multisystem trauma.
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M N GEMENT1. Cauterization : Silver nitrate & electric
2. Nasal packinganterior, posterior or
both3. Ligation of arteries :
a. Ethmoid arteries, anterior & posterior
b. Internal maxillary & sphenopalatinearteries
c. External carotid arteries
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Anterior Nasal packing
Anterior nasal packing :
traditional ribbon gauze pack,
prefabricated expandable packs
intranasal balloons applied to an identified orunidentified bleeding site
mini packdirectly to the bleeding site
Procedure Technique
Local anesthesia : decreasing discomfort,
decrease the risk of apnea, bradycardia, andhypotension
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nterior Nasal packing
If technically possible, placinga single layer of absorbablematerialover the known
bleeding site first followedby the packing material mayprevent rebleeding afterpack removal
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TOOLS :
- Protective eyewear
-Cover gown and mask
-Head lamp and Light source
-Nasal speculum, tongue spatel
-Bayonet pinset
-Suction
-Packing
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TOOLS
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TOOLS
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nterior Nasal packing
The traditional anterior pack of petrolatum gauze (0.5 72-inch) coated
with an antibacterial ointment is firmly packed in a layered fashion toward
the posterior choanae after decongestion and local anesthesia placement
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Anterior Nasal packing
Newer nasal packingmaterialsexpandseveral times in volume
with hydration, makingplacement easier for thephysician and patienthydroxylated polyvinyl
acetal (Merocel) andpolyvinyl alcohol(Expandacell, RhinoRocket)
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Nasal packing posteriorIndicatedfor those patients
failing anterior nasal packs or
who upon evaluation have
known posterior bleeding
Preoperative procedure :
Require careful instruction
to the patient
Intravenous access andmild sedation
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Nasal packing posterior
Technique procedure :
The ideal pack will seat firmly in the posterior nasalcavity against the septum and floor of the noseshould not fill the nasopharynx or depress the softpalate
For the optimum distribution of pressure in theposterior nasal regiona conical-shaped rolledposterior nasal pack with the base oriented posteriorlyand out of the nasopharynx.
The posterior pack is generally used in conjunctionwith an anterior pack to stabilize it
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Monitoring post posterior nasal packing : Should be admitted and monitored in an appropriate hospital
setting.
Pulse oximetry is recommended to follow oxygen saturation.
Maintenance of body fluids is important.
Deep vein thrombosis in the bedridden and elderly patient is ofparticular concern
The gauze packing should be impregnated with antibiotic
ointment, which will decrease the microbial flora present.
The packing is usually left in position for an average of 3 to 5days.
If patients fail packing, they are candidates for further
intervention, determine to undertake a different initial procedure
based on the clinical presentation.
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Nasal packing posterior
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BALLOON PACKS
More available and variedthan the Foley catheter
balloon
Newer typesinclude
double balloons, a compositeof balloon and Merocel
advantage of staying in place
after balloon deflation and
removal.
30Adapted from : Miller, A.J. Epistaxis In : Bailey, B.J. Head & NeckSurgery-Otolaryngology. 2nd ed. 1998
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Complications :
A potential drawback of
balloon packs
Alar or columellar
necrosis
Adapted from : Miller, A.J. Epistaxis In : Bailey, B.J. Head &Neck Surgery-Otolaryngology. 2nded. 1998
Balloon packs
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Epi-dual epistaxis
catheter
Epi-mono epistaxis
catheter
Epi-lave epistaxis
catheter
www.bes.de/rhinologie/epistaxiskatheter
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