RAPID RHINO NASAL PACK

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Clementine Gallagher
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RAPID RHINO NASAL PACK Rhinoceros, Albrecht Dürer, woodcut, 1515, British Museum, London On the first of May in the year 1513 AD (sic), the powerful King of Portugal, Manuel of Lisbon, brought such a

On 20 th May in the year 1515 an Indian Rhinoceros arrived in Lisbon, from India, the gift of the legendary Portuguese explorer Alfonso de Albuquerque to his King, Dom Manuel I of Portugal.

1 RAPID RHINO NASAL PACK Rhinoceros, Albrecht Dürer, woodcut, 1515, British Museum, London On the first of May in the year 1513 AD (sic), the powerful King of Portugal, Manuel of Lisbon, brought such a living animal from India, called the rhinoceros. This is an accurate representation Woodcut inscription for Albrecht Durer s Rhinoceros, On 20 th May in the year 1515 an Indian Rhinoceros arrived in Lisbon, from India, the gift of the legendary Portuguese explorer Alfonso de Albuquerque to his King, Dom Manuel I of Portugal. The creature had been given to Alfonso by the Sultan of Gujurat, Muzafar II. News of its arrival created an instant sensation throughout the rest of Europe. A Rhinoceros had not been seen in Europe since the days of the Roman Empire. The majority of the population of Europe of the time still believed in a great host of mythical beasts that lived on the far edges of the unexplored world, including unicorns, dragons, centaurs and even mermaids.

2 The great age of European exploration meant that many strange marvels were being daily discovered. The news of these discoveries was seriously challenging many engrained medieval conceptions of the wider world. The existence of such creatures as mermaids and unicorns were coming into question as the discoveries grew at an exponential rate in stark contrast with the many previous centuries of stagnation since the days of the Roman Empire. Whilst many old myths and legends were being laid to rest forever some were in fact rediscovered such as the great beast known as the Rhinoceros. Classical sources described many strange animals from distant lands in fanciful even fantastical terms that could not be relied on for accuracy, fact was very difficult to distinguish from fiction in the ancient sources. Many creatures known from antiquity such as the unicorn and the dragon were rapidly being consigned to mere mythology, yet occasionally one would be confirmed such as the Rhinoceros, and when a living example was brought back to Europe it created a sensation no less than if a unicorn had been discovered and bought back alive. Inevitably infallible ancient sources would be consulted in the first instance. Pliny the Elder commented that the Rhinoceros and the Elephant were mortal enemies. To test this out King Manuel decided to pit his Rhinoceros in gladiatorial combat with an Elephant for the amusement of the royal court. Apparently the startled elephant took one look at the fearsome creature and ran for its life. True to the new enlightened scientific spirit of the early Sixteenth century the ancient sources were being increasingly questioned. Many details from these sources were found to be seriously deficient. The Rhinoceros being a case in point. It was left to the brilliant Renaissance artist Albrecht Durer to make the first scientifically accurate drawing of a Rhinoceros in history. It was so accurate in fact that his woodcut image became the standard representation of the animal until the life like depiction of George Stubbs supplanted it 275 years later in Stubbs painted the animal from life. The astounding aspect of Durer s Rhinoceros however was that Durer himself never saw one in real life! He was able to make his depiction from a written description that was sent to him in Nuremberg from an unknown Portuguese author. It was a stunning tribute to the new scientific mindset of accurate observation and description on the part of both the unknown author and Durer that Europe was given the image of the Rhinoceros in the early Fifteenth century. This was fortunate because in 1516 King Manuel decided to pass on his prized possession to the Medici Pope Leo X as a gift in order to gain favour during delicate negations over possession rights of new lands recently discovered in the far off spice islands. Unfortunately the Rhinoceros was lost when the vessel carrying it to the Pope was sunk in a storm of the coast off Liguria. There would not be another live Rhinoceros seen in Europe for over 60 years when a further specimen was delivered from India to King Philip II of Spain in In the 21 st century world of emergency medicine a new Rhinoceros has arrived on the scene in the form of the Rapid Rhino nasal packing device. In the enlightened spirit of our current times here follows an accurate description. Like the description of the ancient Portuguese author it is to be hoped that this description will provide a clear picture of the nature of this rhinoceros for, if not centuries, then at least for years to come. It is to be hoped that older less enlightened Manuelian methods that pitted abrasive dry nasal tampons in mortal combat with our patients nasal mucosas, though providing some temporary amusement can now be avoided. By using a properly lubricated Rapid Rhino a more enlightened Durer type approach is now possible. Our patients nasal mucosas may now be preserved for posterity and our patients will be sparred the amusement of their tormentors.

3 RAPID RHINO NASAL PACK Introduction The Rapid Rhino nasal packing device is used for the control of epistaxis. Its major advantages over the more traditional dry hydrophilic nasal tampon devises include: The balloon conforms to the unique internal nasal anatomy of the patient to provide effective tamponade. The carboxy-methylcellulose hydrocolloid (CMC) gel provides excellent lubrication for easy insertion and withdrawal. Easy withdrawal also allows for earlier removal. The CMC also stimulates hemostasis of bleeding nasal mucosal surfaces. It does this by stimulating platelet aggregation. It is also effective in patients who have been warfarinized. It causes lees pain on insertion and removal. Pack Types RR 550 (length 55 mm) Anterior pack. RR 750 (length 75 mm) Anterior/ Posterior pack Indications For the control of epistaxis. Placement Technique 1. Open the pack and remove the blue plastic tube cover. 2. Soak the pack in sterile water for seconds. Addition of the sterile water produces a self-lubricating surface, which facilitates placement and removal. It also stimulates platelet aggregation, hence promotes hemostasis. Do not use saline. Saline may inhibit the gelling properties of the CMC fabric. Do not apply any type of lubricants or antibiotic ointments to the CMC fabric. These may inhibit both the hemostatic and hydrocolloid properties of the CMC material. 3. Have the patient gently blow their nose to rid the nasal cavity of any excess blood and clots.

4. Insert the RR device into the nasal cavity along the septal floor and parallel to the hard palate, until the plastic proximal fabric ring is well within the nares, (in order to allow the

4 4. Insert the RR device into the nasal cavity along the septal floor and parallel to the hard palate, until the plastic proximal fabric ring is well within the nares, (in order to allow the inflatable cuff to properly inflate) 5. Using a ml syringe, inflate the RR device with air only, whilst holding the pilot cuff to get direct tactile feedback. 6. Monitor the pilot cuff for direct tactile feedback. Stop the inflation when the pilot cuff becomes rounded and feels firm when squeezed. Although the maximum fill capacity of air will most likely never be reached they are as follows: RR 30 mls and RR mls. It is important to note that following initial inflation there may be some loss of tamponade due to the fact that nasal mucosa becomes less inflamed following the application of the RR device. After minutes squeeze the pilot cuff. If the pilot cuff is no longer round and firm add a little more air until firm again. 7. Tape the pilot cuff to the side of the face to avoid migration of the nasal cuff. Removal Technique The RR device allows for relatively early removal because the CMC material will not stick to the wound site. Typically the device can be removed in 24 hours. To remove the device use a ml syringe to evacuate the air completely. Gently slide the deflated cuff out of the nose. CMC material facilitates a comfortable removal, while clot remains in place.

5 References 1. ArthroCare Quick Reference Sheet for Epistaxis, Dr J. Hayes 14 December 2006.

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