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Technical Reports

Epistaxis Simulator

An Innovative Design

Pettineo, Christopher M. BA; Vozenilek, John A. MD, FACEP; Kharasch, Morris MD, FACEP; Wang, Ernest MD, FACEP; Aitchison, Pam RN

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: Winter 2008 - Volume 3 - Issue 4 - p 239-241
doi: 10.1097/SIH.0b013e31816fdd22
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Abstract

Epistaxis is a common complaint seen in the Emergency Department, accounting for approximately 1 in 200 visits in the United States.1 Although a common ailment, significant clinical complications from epistaxis and nasal packing include a compromised airway, hypovolemia, and alar necrosis (resulting from over inflation of the balloon). Although blood loss and airway issues are caused by epistaxis itself, toxic shock is a significant delayed complication resulting from the placement of a nasal tampon. We decided to develop an epistaxis simulator to address this training need and to find innovative uses for our older equipment.

An epistaxis trainer offers the student a chance to participate in nasal packing. Although a commercially made electronic epistaxis simulator has recently become available for 825 USD, we used existing materials to develop a new training tool to help physician-educators at Evanston Northwestern Healthcare add diversity to simulation-based teaching and allow resident-physicians the ability to develop nasal packing skills. The purpose of this project was to develop an epistaxis trainer with the ability to simulate a nosebleed’s response to proper packing.

METHODS

Modify Existing Task Trainer

We used an older “Airway Larry” mannequin because its anatomy allows for easy placement of a simulated anastomotic artery on the lateral wall of the nasal cavity in the approximate location of the middle concha (Fig. 1). Commonly, the lateral branches of the sphenopalatine artery create end-to-end anastomoses with the anterior and posterior ethmoidal arteries. A simulated vessel in this location can create a challenging nosebleed that requires more than bilateral digital pressure to control the bleeding.2 The simulator can be positioned by removing the simulator’s foam legs and revealing a flat inferior plate upon which the simulator is able to sit upright (next to the tools and materials Table 1.). This is also the ideal position for examination of the epistaxis patient.3

FIGURE 1.
FIGURE 1.:
The simulated anastomotic vessel is placed in the approximate location of the middle nasal concha.
Table 1
Table 1:
Materials/Cost

The simulator’s cranial skin covering is open posteriorly and held together with a clear elastic band. Carefully pull the mannequin’s skin forward over its head and expose the superior most vinyl nasal tubing. Grasp the nasal cavity with bayonet forceps approximately 3 cm. posterior to the tip of the nose and make a small stab incision with a no. 11 scalpel just wide enough to thread standard i.v. tubing through. Visualize the scalpel tip through the right nare using a nasal speculum.

Create Anastomotic Vessel

The simulated anastomotic vessel can be made with expired i.v. tubing. Cut the tubing 30 cm from the male adapter, leaving the other end cleanly cut. Using forceps to guide the tube, insert the clean-cut end of the i.v. tubing into the incision in the right nasal cavity and out the right nare. Unscrew the cap on the central venous catheter’s hemostatic valve, also called a twist-activated friction-lock, to reveal a series of four small washers. The washers may also be known as membranes, seals, or valve members but will be referred to as washers in this manuscript. Discard the first thin latex washer, the second thick silicone washer and the third thin hard plastic washer (Fig. 2). The fourth washer/valve acts as a stabilizing cap on the end of the i.v. tubing, preventing the student from dislodging the simulated artery during nasal packing (Fig. 3). Slide the washer over the i.v. tubing so that the brim of the washer is closest to the open end of the tube (Fig. 4). Using a syringe dipped in super glue, carefully apply glue circumferentially to the i.v. tubing and slide the washer up onto the portion of the tube covered with glue. Allow 10 minutes for the glue to dry before cutting the excess tubing flush with the frontal aspect of the washer using a no. 12 scalpel (Fig. 5). A smooth, clean cut is essential because excess tubing protruding into the nasal cavity can snag nasal packing materials and dislodge the simulated vessel.

FIGURE 2.
FIGURE 2.:
The series of washers found inside a hemostatic valve.
FIGURE 3.
FIGURE 3.:
The washer/stabilizer acts as a cap on the simulated artery.
FIGURE 4.
FIGURE 4.:
Thread the cap onto the i.v. tubing.
FIGURE 5.
FIGURE 5.:
Cut the tubing flush with the cap.

Secure Anastomotic Vessel

Carefully apply a thin layer of glue to the inner rim of the washer so that it does not run into the opening of the tube. Gently grasp and pull the tube from the end with the male adapter so that the washer slides into the right nare. The inner rim of the washer should rest flush with the middle concha. Confirm proper placement by visualizing with a nasal speculum. Carefully apply super glue to secure the washer and tubing to the vinyl nasal cavity. Use small drops of glue to secure the tubing across the side of the skull and to prevent the tube from kinking (Fig. 6). Return the cranial skin to its original position and reattach the clear stretchy band with the i.v. tubing running anterior to the elastic band. Depending on the type of i.v. tubing used for construction, a threaded cannula may be necessary to attach the male adapter of the simulator’s vessel to the secondary i.v. tubing.

FIGURE 6.
FIGURE 6.:
The i.v. tubing runs posteriorly from the nasal cavity to the back of the head.

Epistaxis Control Mechanism

The epistaxis control mechanism is a 1000 mL i.v. bag connected to secondary i.v. tubing that is charged with an inflatable pressure infusor. Pump the squeeze bulb on the inflatable pressure infusor to charge the simulated artery and cause blood to run out the right nare. When the simulator is resting on its base and sitting upright, the angle and position of the artery only allows blood to flow out of the right inferior nasal meatus instead of dripping posteriorly down into the stomach. Increase the pressure on the squeeze bulb to increase the flow rate of the epistaxis simulator.

RESULTS

The epistaxis simulator is currently used to teach proper nasal packing procedural skills to emergency medicine resident-physicians at Northwestern University. The epistaxis simulator accommodates several different types of nasal packing, enabling the student to practice a range of techniques. Petrolatum Gauze Overwrap, Merocel, a modified Foley catheter, and rapid Rhino have all been used successfully during epistaxis simulations. The task trainer does not require an attendant during the simulation because the pressurized i.v. bag and gravity ensures the blood flows at a steady rate. This enables the instructor to focus on teaching and evaluating learner technique rather than on operating the device.

Balloon tamponade and nasal packing successfully stop the bleeding. However, applying additional pressure to the vessel can render the treatment ineffective at which time the student must demonstrate a different tactic to regain hemostasis. Successful cautery of the vessel is simulated by locking/kinking the i.v. tubing. In one day, the epistaxis simulator received 15 nasal packings and removals during a procedural skills day for 18 Emergency Medicine resident-physicians (Fig. 7). After every three procedures, squeeze/pressurize the i.v. bag to clear any petrolatum from the artery to prevent buildup over the course the procedural skills set. At the end of the simulation session, clamp and disconnect the i.v. tubing so the artery can be flushed with warm water and air dry.

FIGURE 7.
FIGURE 7.:
Resident-physician Ambrose Insua, MD, practices the insertion of a modified Foley catheter to acquire hemostasis.

CONCLUSIONS

Currently there is one commercial electronic nosebleed trainer sold at the price of $825. The commercial model includes a head, requires batteries, and must be special ordered. The time involved in modifying the airway task trainer took less than 20 minutes given available materials (Table 1.). The design and fabrication of the original prototype did take longer, as did the repairs because the vessel was not fitted with the stabilizing cap to prevent dislodging. The task trainer described in this article represents the final prototype—the third in a series of repairs and modifications to the original model. The simulator does require one consumable, fake blood; otherwise, there is little cost to maintain the epistaxis trainer. It is important to note that the “Airway Larry” task trainer can still be used for its intended purpose; the epistaxis feature is simply a functional modification. We were able to create an epistaxis simulator with no monetary investment using expired supplies, an older CPR manikin and tools also used in the treatment of epistaxis.

REFERENCES

1. Pallin D, Chng Y, McKay M, et al. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med 2005; 46:77–81.
2. Drake R, Vogl W, Mitchell A. Gray’s Anatomy for Students. 1st ed. Philadelphia: Elsevier Inc.; 2005:976–979.
3. Alexander J, Samadi R, Burton J. Nose/Sinus, Essentials of Emergency Medicine. Aghababian RV, ed. Sudbury: Jones and Bartlett; 2006: 228–236.
Keywords:

Simulation; Epistaxis; Nosebleed; Bleeding; Nasal packing; Education; Skills; Procedure; Emergency medicine

© 2008 Lippincott Williams & Wilkins, Inc.