- Email: [email protected]
OR care for epistaxis patients
Evelyn M Brewster, RN
OR care for epistaxis patients Epistaxis, or bleeding from the nose, may be an important symptom of nasal, nasopharyngeal, or sinus pathology. In the case of suspected malignancy, it may be the one entity that encourages the patient to seek early medical assistance. A nosebleed could indicate a systemic disorder such as telangiectasis, hypertension, or leukemia. Trauma, either accidental or surgical, is another cause of bleeding from the nasal cavity. When routine sinus or intranasal procedures are complicated by excessive postoperative bleeding, inadequate surgical hemostasis or a bleeding dyscrasia must be considered. In general, epistaxis is first treated conservatively using sedation, local cauterization, or nasal packing. If these measures fail to control the hemorrhage, surgical intervention becomes the treatment of choice. This paper is structured around the transantral approach for ligation of the internal maxillary artery. It will deal primarily with responsibilities of operating room personnel in planning intraoperative care for the patient scheduled
Evelyn M Brewster, RN, is evening charge nurse, operating room, Massachusetts Eye and Ear Infirmary,Boston. S h e is a graduate of Massachusetts General Hospital.
for surgical correction of severe posterior epistaxis. The typical patient suffering from epistaxis is an obese, hypertensive male with chronic obstructive pulmonary disease. Once the diagnosis of severe posterior epistaxis has been established, the patient is subject to the traumatic and uncomfortable insertion of anterior and posterior nasal packing. These packs are left in place for a t least 48 hours in an attempt to control the bleeding without surgery. During this period the patient can no longer breathe through his nose. Swallowing becomes difficult and hours of mouth breathing dry out the mucous membranes serving to increase his discomfort. Esthetically speaking, several days growth of beard coupled with an offensive odor serve to make the patient’s physical appearance distasteful. Such feelings must not be transmitted to the patient, and good oral hygiene should be provided during this period. Despite the tight packing, bleeding may persist. T h e patient tends to swallow the trickle of blood, thus, the extent of blood loss is deceptive. There have been cases in which the hemorrhage has been likened to a leaking aortic aneurysm. The patient is frequently hypovolemic with a low hemoglobin and hematocrit. Every attempt must be made to rectify hypovolemia before surgery. To compound the trouble, the patient’s temperature is often slightly
AORN Journal, September 1975, Vol 22, No 3
313
The operating room table should be adjustable so its head can be lowered for use under the microscope (left) or raised to facilitate induction and the initial part of the proposed surgery (below).
elevated with a corresponding high white blood cell count. This is a n expected complication due to a secondary infection of the maxillary sinus caused by prolonged packing. If the packing is placed so that the eustachian tube orifices are obstructed, otitis media may also develop. Sleep deprivation and a degree of pack-induced hypoxia may result in a n already apprehensive patient becoming temporarily confused. A nurse aware of the preoperative problems should go with the orderly to accompany the patient to the surgical suite. It is important that the patient be transported in a semisitting position even though he may be under mild sedation. Care should be taken not to dislodge intravenous lines that may be present in two extremities. The operating room nurse should obtain information from unit nurses regarding the amount of blood or its derivatives available. Results of the most recent laboratory tests should be
374
on the chart. Until hypovolemia has been corrected, early hemoglobin or hematocrit readings may be false highs, ie, higher than they actually are, due to hemoconcentration. A slowing pulse rate and a rising blood pressure will indicate that hypovolemia is being corrected by preoperative intravenous therapy. Well-handled transportation will assure minimal delay in the patient’s arrival in the operating room suite. If the surgical staff appears impatient, please understand that the attending physician may have spent long and tedious hours packing and repacking the patient on whom he may now be performing a life-saving procedure. Not only has he been dealing with a n anxious patient, but he has undoubtedly had to answer questions of concerned family members. The anesthesiologist, too, is concerned over the patient’s precarious physical condition. Being asked to ad-
AORN Journal, September 1975, Vol22, No 3
minister general anesthesia to such a person involves a calculated risk. Even though other members of the anesthesia department may be present, the nursing staff should be prepared to offer assistance and support in what is a potentially dangerous induction. The room for the operative procedure is set up by nursing staff not directly involved with the patient. It is imperative that the head of the operating room table used cannot only be lowered for use under the microscope, but also raised to facilitate positioning the patient in reverse Trendelenburg’s for anesthesia induction and the initial part of the proposed surgery. An operating microscope with the proper objective lens and two observation tubes should be draped and ready for use. Check the bulb or change it if the scope has been used previously for a lengthy period of time. Standard equipment that can be set up well in advance to save time during the procedure includes two headlights complete with ex-
Listening to conversation between anesthesia personnel and surgical staff regarding establishing and maintaining an adequate fluid balance can be helpful to all. The circulating nurse should also review the procedure to be followed for obtaining requested fluids from the blood bank. Albumisol or other blood expanders may be administered while waiting for blood to be processed. When positioning the patient on the operating room table, place a thyroid bag under his shoulders. A metal toboggan slipped under the mattress supports the arm and armboard. It assures easy access to IV sites without interference with the position of the surgical team. Removing the hospital gown before surgery starts is one more step to save time should an emergency tracheotomy become necessary. Once the patient is properly positioned, the anesthesiologist should have full charge until the endotracheal tube is safely in place. The obstructive nasal packing makes ventilation for the pa-
A thyroid bag and two toboggans should be in place for positioning the patient for ligation of the internal maxillary artery.
tension cords, double suction setup each equipped with a Yankaur suction tip, and a Bovie unit (preferably handactivated). The dissected skull is often requested to use as an anatomical reference during surgery. Assuring that there is a supply of medicuts, intracaths, and blood filters can save time spent getting items that should be readily available.
tient difficult, and his stomach may be full of blood swallowed when the nasal packing was in place. To prevent this blood from welling up into the pharynx, a rapid induction with cricoid pressure is tried. Vital to the success of induction and intubation is the cricoid pressure maneuver, whereby, compressure on the cricoid membrane brings pressure to
AORN Journal, September 1975, Vol 22, No 3
375
Tracheotomy instruments.
Nasal and nasopharyngeal instruments used in pack removal.
bear on the esophagus thus diminishing the chance of stomach contents emptying into the pharynx. The maneuver must be done with full concentration as long as requested by the anesthesiologist. Despite these precautions, blood may still present into the pharynx. If the endotracheal tube cannot be passed within a few seconds with the aid of vigorous suction and the patient in
376
reverse Trendelenburg’s position, an immediate tracheotomy must be performed. Communication between all personnel involved is imperative, and both surgeons and scrub nurse should be in the room, gowned and gloved, ready to perform a tracheotomy should it become necessary. Once the endotracheal tube is in place and properly inflated, the unsavory task of removing the nasal packing begins.
AORN Journal, September 1975, Vol 22, No 3
Included in instruments used in the Caldwell-tuc operation are a modified Weitlaner or Beckman self-retaining retractor, Lempert curettes.
The pterygomaxillary fossa instrument kit contains hemostatic clips, dispenser, and applicator, artery hooks, dissectors, knives, suction tips, and self-locking hemostatic clips.
This may be done a t this stage or a t the conclusion of surgery. A prep table with an adequate kit of nasal and nasopharyngeal instruments is set u p for this procedure. The patient’s face should be cleansed with hydrogen peroxide to remove dried blood prior to prepping. Following induction and intubation a potentially stressful situation now becomes a smoothly running, surgical procedure to ligate the internal max-
illary artery. A Caldwell-Luc or radical antrum is performed to gain access to the pterygomaxillary fossa. Once the posterior wall is exposed, a modified Weitlaner or Beckman self-retaining retractor is applied. The remaining surgery is performed under a binocular operating microscope with either a 250 or 300mm objective lens. The posterior wall of the maxillary sinus is easily broken through with a small chisel or
AORN Journal, September 1975, Vol 22, No 3
377
sharp Lempert curette. Careful dissection with meticulous control of bleeding by electrocoagulation is now employed. The oozing artery and its branches are exposed, identified, and ligated with self-locking hemostatic clips. The posterior mucosal flap is then replaced and covered with absorbable gelatin sponges, If bleeding has been excessive during surgery, a nasoantral window may be cut to establish drainage. Finally the Caldwell-Luc incision is loosely closed with absorbable suture material. Postoperative packing is seldom necessary. A portable chest film may be ordered a t the conclusion of surgery to rule out aspiration of blood and gastric juices during induction. The x-ray may be taken in the operating room or after admission to the recovery room. It. is not unusual for radiographic findings to reveal chemical pneumonia. Early diagnosis and subsequent treatment of aspiration can improve the patient’s chances for an uneventful postoperative course. The optimum in intraoperative care of the patient with epistaxis can be obtained only through careful planning and effective action. An awareness of the patient’s physical and emotional needs, i n t i m a t e knowledge of t h e planned surgical procedure, and an appreciation of the problems faced by all concerned should lead to satisfac0 tion for a job well done. References DeWeese and Saunders. Textbook of Otolaryngology, 2nd ed. (St Louis: C V Mosby Co, 1964). Discussion regarding anesthesia problems. T J Keenam, MD, assistant director, anesthesia department; and John Donlon, MD, staff anesthesiologist, Massachusetts Eye and Ear Infirmary, Boston. Montgomery, William W. Surgery of the Upper Respiratory System. (Philadelphia: Lea and Febiger, 1971).
378
AORN-Edith D Hall scholarship recipients The AORN Scholarship Board has announced recipients of the AORN-Edith D Hall scholarships for the application period ending May 15. Selections were made by the board at a meeting at Headquarters in June. The recipients are: Carol L Baugh, Richmond, Ky, a member of the Greater Cincinnati and Hamilton chapter, working on a BS degree at Eastern Kentucky University, Richmond; Barbara Bennett, Palatine, 111, a member of the Chicago chapter, attending the University of Illinois in the bachelor of science program; Kathryn H Glasgow, Lynchburg, Va, a BS student at the University of Virginia, Charlottesvilie, and a member of the Blue Ridge Area chapter; Laurel B Kay, Provo, Utah, a student at Brigham Young University, Provo, a BS candidate, and a member of the Central Southern Utah chapter; Katherine A Kirchner, East Islip, NY, a BS student at Long Island University, Greenvale, NY, and a member of the Suffolk County chapter; Kathleen Lamb, North Tonawanda, NY, a member of the Western New York chapter and a BS and MS student at the State University of New York at Buffalo: M Marcella Leight, Allison Park, Pa, a member of the Pittsburgh chapter and a BS student at Duquesne University, Pittsburgh; LeAnne Lorenz, Bremerton, Wash, a student at Pacific Lutheran University, Tacoma, Wash, a member 5f the Evergreen chapter, and a BS candidate. Applications are now being accepted for the period ending Jan 15, 1976. Criteria for applicants may be found in the scholarship article appearing periodically in the AORN Journal or may be obtained by writing to the AORN Education Department.
AORN Journal, September 1975, Vol 22, No 3
OR care for epistaxis patients Epistaxis, or bleeding from the nose, may be an important symptom of nasal, nasopharyngeal, or sinus pathology. In the case of suspected malignancy, it may be the one entity that encourages the patient to seek early medical assistance. A nosebleed could indicate a systemic disorder such as telangiectasis, hypertension, or leukemia. Trauma, either accidental or surgical, is another cause of bleeding from the nasal cavity. When routine sinus or intranasal procedures are complicated by excessive postoperative bleeding, inadequate surgical hemostasis or a bleeding dyscrasia must be considered. In general, epistaxis is first treated conservatively using sedation, local cauterization, or nasal packing. If these measures fail to control the hemorrhage, surgical intervention becomes the treatment of choice. This paper is structured around the transantral approach for ligation of the internal maxillary artery. It will deal primarily with responsibilities of operating room personnel in planning intraoperative care for the patient scheduled
Evelyn M Brewster, RN, is evening charge nurse, operating room, Massachusetts Eye and Ear Infirmary,Boston. S h e is a graduate of Massachusetts General Hospital.
for surgical correction of severe posterior epistaxis. The typical patient suffering from epistaxis is an obese, hypertensive male with chronic obstructive pulmonary disease. Once the diagnosis of severe posterior epistaxis has been established, the patient is subject to the traumatic and uncomfortable insertion of anterior and posterior nasal packing. These packs are left in place for a t least 48 hours in an attempt to control the bleeding without surgery. During this period the patient can no longer breathe through his nose. Swallowing becomes difficult and hours of mouth breathing dry out the mucous membranes serving to increase his discomfort. Esthetically speaking, several days growth of beard coupled with an offensive odor serve to make the patient’s physical appearance distasteful. Such feelings must not be transmitted to the patient, and good oral hygiene should be provided during this period. Despite the tight packing, bleeding may persist. T h e patient tends to swallow the trickle of blood, thus, the extent of blood loss is deceptive. There have been cases in which the hemorrhage has been likened to a leaking aortic aneurysm. The patient is frequently hypovolemic with a low hemoglobin and hematocrit. Every attempt must be made to rectify hypovolemia before surgery. To compound the trouble, the patient’s temperature is often slightly
AORN Journal, September 1975, Vol 22, No 3
313
The operating room table should be adjustable so its head can be lowered for use under the microscope (left) or raised to facilitate induction and the initial part of the proposed surgery (below).
elevated with a corresponding high white blood cell count. This is a n expected complication due to a secondary infection of the maxillary sinus caused by prolonged packing. If the packing is placed so that the eustachian tube orifices are obstructed, otitis media may also develop. Sleep deprivation and a degree of pack-induced hypoxia may result in a n already apprehensive patient becoming temporarily confused. A nurse aware of the preoperative problems should go with the orderly to accompany the patient to the surgical suite. It is important that the patient be transported in a semisitting position even though he may be under mild sedation. Care should be taken not to dislodge intravenous lines that may be present in two extremities. The operating room nurse should obtain information from unit nurses regarding the amount of blood or its derivatives available. Results of the most recent laboratory tests should be
374
on the chart. Until hypovolemia has been corrected, early hemoglobin or hematocrit readings may be false highs, ie, higher than they actually are, due to hemoconcentration. A slowing pulse rate and a rising blood pressure will indicate that hypovolemia is being corrected by preoperative intravenous therapy. Well-handled transportation will assure minimal delay in the patient’s arrival in the operating room suite. If the surgical staff appears impatient, please understand that the attending physician may have spent long and tedious hours packing and repacking the patient on whom he may now be performing a life-saving procedure. Not only has he been dealing with a n anxious patient, but he has undoubtedly had to answer questions of concerned family members. The anesthesiologist, too, is concerned over the patient’s precarious physical condition. Being asked to ad-
AORN Journal, September 1975, Vol22, No 3
minister general anesthesia to such a person involves a calculated risk. Even though other members of the anesthesia department may be present, the nursing staff should be prepared to offer assistance and support in what is a potentially dangerous induction. The room for the operative procedure is set up by nursing staff not directly involved with the patient. It is imperative that the head of the operating room table used cannot only be lowered for use under the microscope, but also raised to facilitate positioning the patient in reverse Trendelenburg’s for anesthesia induction and the initial part of the proposed surgery. An operating microscope with the proper objective lens and two observation tubes should be draped and ready for use. Check the bulb or change it if the scope has been used previously for a lengthy period of time. Standard equipment that can be set up well in advance to save time during the procedure includes two headlights complete with ex-
Listening to conversation between anesthesia personnel and surgical staff regarding establishing and maintaining an adequate fluid balance can be helpful to all. The circulating nurse should also review the procedure to be followed for obtaining requested fluids from the blood bank. Albumisol or other blood expanders may be administered while waiting for blood to be processed. When positioning the patient on the operating room table, place a thyroid bag under his shoulders. A metal toboggan slipped under the mattress supports the arm and armboard. It assures easy access to IV sites without interference with the position of the surgical team. Removing the hospital gown before surgery starts is one more step to save time should an emergency tracheotomy become necessary. Once the patient is properly positioned, the anesthesiologist should have full charge until the endotracheal tube is safely in place. The obstructive nasal packing makes ventilation for the pa-
A thyroid bag and two toboggans should be in place for positioning the patient for ligation of the internal maxillary artery.
tension cords, double suction setup each equipped with a Yankaur suction tip, and a Bovie unit (preferably handactivated). The dissected skull is often requested to use as an anatomical reference during surgery. Assuring that there is a supply of medicuts, intracaths, and blood filters can save time spent getting items that should be readily available.
tient difficult, and his stomach may be full of blood swallowed when the nasal packing was in place. To prevent this blood from welling up into the pharynx, a rapid induction with cricoid pressure is tried. Vital to the success of induction and intubation is the cricoid pressure maneuver, whereby, compressure on the cricoid membrane brings pressure to
AORN Journal, September 1975, Vol 22, No 3
375
Tracheotomy instruments.
Nasal and nasopharyngeal instruments used in pack removal.
bear on the esophagus thus diminishing the chance of stomach contents emptying into the pharynx. The maneuver must be done with full concentration as long as requested by the anesthesiologist. Despite these precautions, blood may still present into the pharynx. If the endotracheal tube cannot be passed within a few seconds with the aid of vigorous suction and the patient in
376
reverse Trendelenburg’s position, an immediate tracheotomy must be performed. Communication between all personnel involved is imperative, and both surgeons and scrub nurse should be in the room, gowned and gloved, ready to perform a tracheotomy should it become necessary. Once the endotracheal tube is in place and properly inflated, the unsavory task of removing the nasal packing begins.
AORN Journal, September 1975, Vol 22, No 3
Included in instruments used in the Caldwell-tuc operation are a modified Weitlaner or Beckman self-retaining retractor, Lempert curettes.
The pterygomaxillary fossa instrument kit contains hemostatic clips, dispenser, and applicator, artery hooks, dissectors, knives, suction tips, and self-locking hemostatic clips.
This may be done a t this stage or a t the conclusion of surgery. A prep table with an adequate kit of nasal and nasopharyngeal instruments is set u p for this procedure. The patient’s face should be cleansed with hydrogen peroxide to remove dried blood prior to prepping. Following induction and intubation a potentially stressful situation now becomes a smoothly running, surgical procedure to ligate the internal max-
illary artery. A Caldwell-Luc or radical antrum is performed to gain access to the pterygomaxillary fossa. Once the posterior wall is exposed, a modified Weitlaner or Beckman self-retaining retractor is applied. The remaining surgery is performed under a binocular operating microscope with either a 250 or 300mm objective lens. The posterior wall of the maxillary sinus is easily broken through with a small chisel or
AORN Journal, September 1975, Vol 22, No 3
377
sharp Lempert curette. Careful dissection with meticulous control of bleeding by electrocoagulation is now employed. The oozing artery and its branches are exposed, identified, and ligated with self-locking hemostatic clips. The posterior mucosal flap is then replaced and covered with absorbable gelatin sponges, If bleeding has been excessive during surgery, a nasoantral window may be cut to establish drainage. Finally the Caldwell-Luc incision is loosely closed with absorbable suture material. Postoperative packing is seldom necessary. A portable chest film may be ordered a t the conclusion of surgery to rule out aspiration of blood and gastric juices during induction. The x-ray may be taken in the operating room or after admission to the recovery room. It. is not unusual for radiographic findings to reveal chemical pneumonia. Early diagnosis and subsequent treatment of aspiration can improve the patient’s chances for an uneventful postoperative course. The optimum in intraoperative care of the patient with epistaxis can be obtained only through careful planning and effective action. An awareness of the patient’s physical and emotional needs, i n t i m a t e knowledge of t h e planned surgical procedure, and an appreciation of the problems faced by all concerned should lead to satisfac0 tion for a job well done. References DeWeese and Saunders. Textbook of Otolaryngology, 2nd ed. (St Louis: C V Mosby Co, 1964). Discussion regarding anesthesia problems. T J Keenam, MD, assistant director, anesthesia department; and John Donlon, MD, staff anesthesiologist, Massachusetts Eye and Ear Infirmary, Boston. Montgomery, William W. Surgery of the Upper Respiratory System. (Philadelphia: Lea and Febiger, 1971).
378
AORN-Edith D Hall scholarship recipients The AORN Scholarship Board has announced recipients of the AORN-Edith D Hall scholarships for the application period ending May 15. Selections were made by the board at a meeting at Headquarters in June. The recipients are: Carol L Baugh, Richmond, Ky, a member of the Greater Cincinnati and Hamilton chapter, working on a BS degree at Eastern Kentucky University, Richmond; Barbara Bennett, Palatine, 111, a member of the Chicago chapter, attending the University of Illinois in the bachelor of science program; Kathryn H Glasgow, Lynchburg, Va, a BS student at the University of Virginia, Charlottesvilie, and a member of the Blue Ridge Area chapter; Laurel B Kay, Provo, Utah, a student at Brigham Young University, Provo, a BS candidate, and a member of the Central Southern Utah chapter; Katherine A Kirchner, East Islip, NY, a BS student at Long Island University, Greenvale, NY, and a member of the Suffolk County chapter; Kathleen Lamb, North Tonawanda, NY, a member of the Western New York chapter and a BS and MS student at the State University of New York at Buffalo: M Marcella Leight, Allison Park, Pa, a member of the Pittsburgh chapter and a BS student at Duquesne University, Pittsburgh; LeAnne Lorenz, Bremerton, Wash, a student at Pacific Lutheran University, Tacoma, Wash, a member 5f the Evergreen chapter, and a BS candidate. Applications are now being accepted for the period ending Jan 15, 1976. Criteria for applicants may be found in the scholarship article appearing periodically in the AORN Journal or may be obtained by writing to the AORN Education Department.
AORN Journal, September 1975, Vol 22, No 3