Hemorrhagic emergencies in otolaryngology can present significant challenges to the early practitioner. The development of procedural skills, clinical decision making, effective communication strategies, and leadership remain critical to ensuring positive patient outcomes. Procedural task trainers and simulation-based complex scenarios provide safe and effective learning environments for young practitioners to build confidence and develop such skills. This article reviews the principles of managing epistaxis and postoperative neck hematoma geared toward early learners by providing a road map for educators to use in simulation-based curriculums.
Key learning points
At the end of this article, early practitioners will:
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Be able to identify the common presentations of hemorrhage in otolaryngology.
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Understand how knowledge of relevant anatomy helps to form the basis for effective management.
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Be able to identify the most common sources of bleeding in otolaryngology emergencies and how can they be controlled.
At the end of this article, expert practitioners/educators will:
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Understand how management of head and neck hemorrhage can be taught and practiced.
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Understand how early practitioner skill and confidence can be developed in the management of hemorrhage in otolaryngology.
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Know which educational tools are available to train early practitioners in control of hemorrhage techniques.
Introduction
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Traditional model was experiential: “see one, do one, teach one.”
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Today’s early learners often have initial experience as the first responder while the junior resident on call.
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Modern limitations on time in training and concerns surrounding patient safety have produced practice gaps for the early practitioner.
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Learners may not encounter a bleeding event or emergency early in their practice when perhaps more supported by an expert teacher.
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The learner’s initial management may be suboptimal if unfamiliar with hemostatic procedures and equipment, thus posing potential concerns regarding patient safety.
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Given the current challenges of expeditiously bringing the early, inexperienced learner to a basic level of safe practice and competence, new educational models have been developed to facilitate this process. Although traditional didactics such as lectures and the Socratic method of teaching rounds remain valuable, surgical simulation has entered the expert practitioner’s educational armamentarium. Surgical simulation has emerged as effective tool to help build learner confidence and early skill acquisition. Here, we briefly describe 2 otolaryngology hemorrhagic emergencies that can be taught and practiced in a simulated environment. Simulation must be used in the context of a thoughtful curriculum. A robust discussion of curriculum development and the process of prebriefing and debriefing is outside the scope of this article; however, these processes remain vital to the successful implementation of surgical simulation.
Introduction
- •
Traditional model was experiential: “see one, do one, teach one.”
- •
Today’s early learners often have initial experience as the first responder while the junior resident on call.
- •
Modern limitations on time in training and concerns surrounding patient safety have produced practice gaps for the early practitioner.
- ○
Learners may not encounter a bleeding event or emergency early in their practice when perhaps more supported by an expert teacher.
- ○
The learner’s initial management may be suboptimal if unfamiliar with hemostatic procedures and equipment, thus posing potential concerns regarding patient safety.
- ○
Given the current challenges of expeditiously bringing the early, inexperienced learner to a basic level of safe practice and competence, new educational models have been developed to facilitate this process. Although traditional didactics such as lectures and the Socratic method of teaching rounds remain valuable, surgical simulation has entered the expert practitioner’s educational armamentarium. Surgical simulation has emerged as effective tool to help build learner confidence and early skill acquisition. Here, we briefly describe 2 otolaryngology hemorrhagic emergencies that can be taught and practiced in a simulated environment. Simulation must be used in the context of a thoughtful curriculum. A robust discussion of curriculum development and the process of prebriefing and debriefing is outside the scope of this article; however, these processes remain vital to the successful implementation of surgical simulation.
Epistaxis
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Knowledge of the common sources of bleeding from the nose and causative factors (hypertension, antiplatelet/anticoagulation, dry oxygen delivery nasal cannula O 2 , winter weather).
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Use of equipment to stop epistaxis (headlight, suction, nasal speculum, bayonet forceps, various nasal packing, and hemostatic products).
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Postpacking management knowledge (management of causative factors, antibiotic coverage, admission to intensive care for posterior packing, plan for packing removal).
A curriculum in epistaxis management
Epistaxis is the most common otolaryngologic emergency, reported to occur in up to 60% of the general population. Effective management poses challenges to the earlier learner who must integrate principles in resuscitation and airway management, nasal anatomy, and sophisticated knowledge of the equipment and methods in epistaxis control ( Figs. 1 and 2 , Table 1 ).
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Uses a task-specific skills trainer.
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Requires an epistaxis simulator.
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Easily designed and adapted model using Laerdal Airway Trainer (Laerdal Medical Corporation Wappingers Falls, New York).
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May also consider cadaver based simulators as described by Chin and colleagues.
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Hands-on practice with simulator with real-time feedback from expert practitioners/educators
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Skill competency and confidence can be assessed using a task specific check list and global rating scale.
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The goal is to improve skill and confidence in placement of anterior and posterior nasal packs and identify those patients who may require escalation of care.
| Anterior Epistaxis | Posterior Epistaxis | |
|---|---|---|
| Incidence | More common (90%) | Less common (10%) |
| Source | Anterior to the plane of pyriform aperture | Posterior to the plane of pyriform aperture |
| Blood flows | Out from the front of nose | Back into the throat |
| Age | Children or young adults | >40 y |
| Localization | Easy | Difficult |
| Common site | Keisselbach’s plexus | Woodruff’s plexus |
| Common cause | Local trauma | Spontaneous, skull base of facial trauma |
| Severity | Less severe | Severe |
| Treatment | Usually controlled by local pressure or anterior pack | Requires hospitalization and posterior nasal pack is often required |
Outline of learner curriculum
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Epistaxis is typically described as anterior or posterior based on the source of the bleeding vessel(s).
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Anatomic distinction provides important basis for management.
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Anterior epistaxis:
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90% of all nosebleeds.
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Most commonly, Kiesselbach’s plexus and the anterior septum.
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Formed by anastomosis of the septal branch of the anterior ethmoidal artery, the lateral nasal branch of the sphenopalatine artery (SPA), or the septal branch of the superior labial artery.
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Bleeding from anterior nostril is usually of lower volume.
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Posterior Epistaxis
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Arises most commonly from posterolateral branches of the SPA.
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Bleed into the posterior pharynx; may be high volume, brisk.
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Knowledge about the anatomic position of the SPA is very important owing to the need for possible surgical ligation in the case of refractory posterior bleeding.
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Enters the nose through the sphenopalatine foramen at the posterior end of the middle turbinate.
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If bleeding is from a high posterior source, anterior and posterior ethmoid arteries must be considered.
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Risk factors and important components of history
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Anticoagulation.
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Hereditary hemorrhagic telangiectasia.
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Blood dyscrasias, platelet disorders, von Willebrand disease, and hemophilia.
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Aneurysms of the head and neck vasculature secondary to prior regional surgery.
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Nasal neoplasms.
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Most common associated with epistaxis: juvenile nasopharyngeal angiofibroma, sinonasal melanoma, squamous cell carcinoma, adenoid cystic carcinoma, and inverted papilloma.
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Chronic alcohol abuse.
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Intranasal steroid use.
Equipment and supplies
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Nasal decongestant spray, such as oxymetazoline
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Local anesthetic, such as 2% lidocaine
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Headlight
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Bayonet forceps
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Nasal speculum
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Frazier tip suction
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Lubricating jelly, bacitracin, mupirocin or other antistaphylococcal ointment
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Anterior nasal packs: Merocel (Medtronic Minneapolis, MN), Rapid Rhino (Shippert Medical Technologies Centennial, Colorado) (4.5 cm pediatric, 5.5 cm adult)
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Posterior nasal packs: Rapid Rhino (7.5 cm), Epistat (Medtronic Xomed Minneapolis, MN), urinary balloon catheter
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Additional materials: silver nitrate cautery sticks, thrombogenic agents: Fibrillar, Surgiflo, thrombin spray, transexamic acid.
A stepwise approach should be followed in the treatment of epistaxis. Nonsurgical treatments should initially be pursued including topical treatment, cauterization, thrombogenic therapies, and nasal packs. These treatments will generally stop bleeding in 90% of patients. If the bleed is refractive to these treatments, surgical intervention should be pursued.
Evaluate hemodynamic and airway status
Initial Management
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Check pulse and blood pressure.
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Asses airway: secure airway with elective intubation if patient unable to protect airway owing to excessive bleeding.
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Ensure intravenous access and volume resuscitation as indicated.
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Treat hypertension.
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Initial laboratory tests: Full blood examination, coagulation panel.
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