Treatment for nosebleeds

The goal of treatment for nosebleeds

Stopping nosebleeds.

Drug treatment for nosebleeds

The most common cause of nosebleeds in adults is arterial hypertension. Nosebleeds most often occur against the background of a hypertensive crisis, which requires the appointment of hypotensive therapy.

Recurrent nosebleeds in hypertension occur due to chronic DIC syndrome and a relative deficiency of plasma coagulation factors caused by erythrocytosis - polycythemia (i.e. deficiency of coagulation factors per unit of blood cells), which leads to the formation of loose erythrocyte thrombi, which are easily rejected when removing tampons from the nasal cavity. To correct these disorders, intravenous drip administration of antiplatelet agents and hemodilution agents is necessary: actovegin (400 mg per 200 ml of 0.9% sodium chloride solution or 250 ml of infusion solution), pentoxifylline {100 mg per 200 ml of 0.9% sodium chloride solution), rheomacrodex (200 ml). In case of persistent, recurrent nosebleeds, transfusion of fresh frozen plasma and factor VIII of blood coagulation can be prescribed. The administration of a 5% solution of aminocaproic acid is contraindicated in this group of patients.

The main method of treating hemophilic hemorrhages is replacement therapy. It should be noted that factor VIII is labile and is practically not preserved in preserved blood and native plasma. In this regard, only blood products prepared under conditions that ensure the preservation of VIII are suitable for replacement therapy.

The drug of choice for the treatment of massive bleeding in patients with hemophilia is the drug eptacog alfa activated - a recombinant VIIa blood coagulation factor.

This drug in pharmacological doses binds to a large amount of tissue factor, forming an eptacog-tissue factor complex, which enhances the initial activation of factor X. In addition, eptacog alpha in the presence of calcium ions and anionic phospholipids is able to activate factor X on the surface of activated platelets, acting "bypassing" the coagulation cascade system, which makes it a universal hemostatic agent. Eptacog alpha acts only at the site of bleeding and does not cause systemic activation of the blood clotting process. It is available as a powder for the preparation of an injection solution. After dilution, the drug is administered intravenously for 2-5 minutes as a bolus injection. The dose of the drug is 3-6 KED / kg of body weight. The drug is administered every 2 hours until the onset of the clinical effect. Side effects: chills, headache, nausea, vomiting, weakness, changes in blood pressure, redness, itching. Contraindications: hypersensitivity to cow, mouse, and hamster proteins. During pregnancy, use for vital indications. Cases of overdose and drug interactions are not indicated.

Treatment of thrombocytopenia should be strictly pathogenetic; among acquired thrombocytopenias, immune lesions requiring glucocorticoids are most common. The daily dose of prednisolone is 1 mg/kg of body weight: it is divided into 3 doses. After normalization of the platelet count, the dose of glucocorticoids is reduced until the hormones are completely discontinued.

Replacement therapy for thrombocytopenic hemorrhagic syndrome involves transfusion of platelet mass. Indications for transfusion of platelet mass are determined by the physician based on the dynamics of the clinical picture. In the absence of spontaneous bleeding and prospects for planned surgical interventions, a low, even critical level of platelets (less than 30x10 ⁹ /l) is not an indication for transfusion of platelet mass. If nosebleeds against the background of thrombocytopenia cannot be stopped within 1 hour, it is necessary to transfuse 15-20 doses of platelet mass (I dose of platelet mass contains 10 ⁸ platelets) regardless of the number of platelets in the analysis.

Aminocaproic acid in relatively small doses (0.2 g/kg or 8-12 g per adult patient per day) reduces bleeding in many disaggregation thrombocytopathies, enhances the reaction of release of intraplasmic factors, reduces the time of capillary bleeding. The hemostatic effect of aminocaproic acid is explained not only by its stimulating effect on the function of platelets and inhibitory effect on fibrinolysis, but also by other effects - normalizing effect on permeability and resistance of capillaries, inhibition of the Hageman factor and the kallikrein bridge between XII and VII factors. This, apparently, explains the fact that aminocaproic acid reduces bleeding not only in qualitative defects of platelets, but also in thrombocytopenia. Treatment with this drug is not indicated in the presence of macrohemaguarne and DIC syndrome. The drug is administered intravenously by drip, 100 ml of 5-6% solution.

Cyclic amino acids, aminomethylbenzoic acid and tranexamic acid, have pharmacotherapeutic effects similar to those of aminocaproic acid. These drugs significantly reduce microcirculatory bleeding (nosebleeds, uterine bleeding). Tranexamic acid is the most widely used. It is prescribed orally at 500-1000 mg 4 times a day. In case of massive bleeding, 1000-2000 mg of the drug diluted in 0.9% sodium chloride solution is administered intravenously by jet stream. The dose and route of administration are then determined by the clinical situation and laboratory parameters of the blood clotting process.

In thrombocytopathic and thrombocytopenic bleeding, ztamzilat is used. The drug has virtually no effect on the number and function of platelets, but increases the resistance of the endothelial cell membrane, thereby correcting secondary vasopathy against the background of platelet hemostasis disorders. Usually, ztamzilat is prescribed orally at 0.5 g 3-4 times a day; in case of massive nosebleeds, intravenous jet injection of a 12.5% solution of 2 ml 2 times a day is prescribed, an increase in the dose to 4 ml (3-4 times a day) is also permissible.

In case of nosebleeds caused by liver damage (including alcohol), it is necessary to compensate for the lack of vitamin K. Deficiency of K-vitamin-dependent factors requires intensive therapy due to rapid progression of the disease. Good effect is achieved by transfusion of donor plasma or intravenous administration of concentrate of K-vitamin-dependent factors. At the same time, menadione sodium bisulfite is prescribed at a dose of 1-3 mg. Treatment with this drug alone is not enough, since its effect on the level of K-vitamin-dependent factors begins after 10 hours, and their noticeable increase occurs after 16-24 hours, and improvement of prothrombin test indicators - only after 48-72 hours after the start of treatment. Therefore, ongoing bleeding always requires transfusion therapy.

In case of massive bleeding caused by taking indirect anticoagulants, plasma transfusions are performed in large quantities (up to 1.0-1.5 l per day in 2-3 doses), the dose of menadione sodium bisulfite is increased to 20-30 mg per day (in severe cases - up to 60 mg). The effect of menadione sodium bisulfite is potentiated by prednisolone (up to 40 mg per day). Vitamin P, ascorbic acid and calcium preparations are not effective in these cases.

In case of bleeding caused by an overdose of sodium heparin, it is necessary to reduce the dose of the latter or skip 1-2 injections, and then cancel it, gradually reducing the dose. Along with this, it is possible to prescribe the introduction of a 1% solution of protamine sulfate intravenously at a dose of 0.5-1 mg for every 100 IU of sodium heparin.

During treatment with streptokinase or urokinase, nosebleeds may occur with a rapid drop in blood fibrinogen levels below 0.5-1.0 g/l. In these cases, when streptokinase is discontinued, sodium heparin must be prescribed and fresh frozen plasma, which contains a significant amount of plasminogen and antithrombin III, must be infused for replacement purposes. Such therapy requires daily monitoring of blood antithrombin III levels.

Calcium preparations are also used to improve hemostasis, since the presence of Ca ²⁺ ions is necessary for the conversion of prothrombin into thrombin, polymerization of fibrin, and aggregation and adhesion of platelets. However, calcium is contained in the blood in quantities sufficient for blood clotting. Even with hypocalcemic convulsions, blood clotting and platelet aggregation are not impaired. In this regard, the introduction of calcium salts does not affect the coagulation properties of the blood, but reduces the permeability of the vascular wall.

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Techniques for stopping nosebleeds

First of all, it is necessary to calm the patient and free him from all objects constricting his neck and body (tie, belt, tight clothing), give him a semi-sitting position. Then put an ice pack or cold water on the bridge of his nose, and a heating pad at his feet. In case of minor nosebleeds from the anterior sections of the nasal septum of one of the halves of the nose, insert a cotton swab with a 3% solution of hydrogen peroxide into it and squeeze the wings of the nose with your fingers for several minutes. If the localization of the bleeding vessel is precisely established (by a pinpoint pulsating "fountain"), then after application anesthesia with a 3-5% solution of dicaine mixed with a few drops of adrenaline (1:1000), this vessel is cauterized (cauterization) with the so-called lapis "pearl", electrocautery or YAG-neodymium laser; cryodestruction can also be used. The "pearl" is made as follows: silver nitrate crystals are collected on the tip of an aluminum wire and carefully heated over a spirit lamp flame until they melt and form a round bead, which is tightly fused to the end of the aluminum wire. Cauterization is carried out only on the side of the bleeding vessel, however, if this procedure is necessary and, on the other hand, to prevent the formation of a perforation of the nasal septum, it is carried out no earlier than 5-8 days after the first cauterization. After cauterization, the patient should not strain, blow his nose or independently exert mechanical effects on the crusts formed on the nasal septum. After cauterization, cotton swabs soaked in Vaseline oil, carotolin or sea buckthorn oil are inserted into the nasal cavity 2-3 times a day.

If the curvature of the nasal septum or its ridge is an obstacle to stopping nosebleeds, then preliminary resection of its deformed part is possible. Often, for radical stopping of nosebleeds, they resort to exfoliation of the mucous membrane with the perichondrium and cutting of the vessels of the nasal septum. If the presence of a bleeding polyp of the nasal septum is established, then it is removed together with the underlying section of cartilage.

To stop nosebleeds, anterior, posterior, or combined nasal tamponade is often used.

Anterior nasal tamponade is used in cases where the localization of the source of bleeding is obvious (anterior parts of the nasal septum) and stopping nosebleeds by simple methods is ineffective.

There are several methods of anterior nasal tamponade. To perform it, you need gauze tampons 1-2 cm wide and of different lengths (from 20 cm to 1 m) soaked in vaseline oil and a broad-spectrum antibiotic, nasal mirrors of different lengths, nasal or ear forceps, a solution of cocaine (10%) or dicaine (5%) mixed with a few drops of adrenaline chloride (1:1000) for application anesthesia.

Mikulich's method

A 70-80 cm long tampon is inserted into the nasal cavity in the direction of the choana and tightly laid in the form of loops. The front end of the tampon is wound around a wad of cotton wool, forming an "anchor". A sling-like bandage is applied on top. When the bandage is soaked with blood, it is replaced without removing the tampon. The disadvantage of this type of tamponade is that the back end of the tampon can penetrate the pharynx and cause a gag reflex, and if it gets into the larynx, signs of its obstruction.

Lawrence-Likhachev method

It is an improved version of Mikulich's method. A thread is tied to the inner end of the tampon, which remains outside together with the front end of the tampon and is attached to the anchor, thereby preventing the back end of the tampon from slipping into the pharynx. A.G. Likhachev improved Lawrence's method by suggesting to pull the back end of the tampon into the back sections of the nose and thus not only prevent it from falling into the nasopharynx, but also to compact the nasal tamponade in its back sections.

V.I. Voyachek's method

A loop tampon is inserted into one of the halves of the nose to its full depth, the ends of which remain outside. Short (insertion) tampons are successively inserted into the resulting loop to the full depth of the nasal cavity, without gathering them into folds. Thus, several insertion tampons are placed in the cavity, pushing the loop tampon apart and exerting pressure on the tissues of the inner nose. This method can be considered the most gentle, since the subsequent removal of the insertion tampons is not associated with their “tearing off” from the tissues of the nose, but occurs in the environment of other tampons. Before removing the loop tampon, its inner surface is irrigated with an anesthetic and a 3% solution of hydrogen peroxide, as a result of which, after some exposure, it is easily removed by traction on the lateral end.

In anterior nasal tamponade, tampons are kept for 2-3 days, after which they are removed, and the tamponade is repeated if necessary. Partial removal of the tampon (or tampons in the Voyachek method) is also possible to loosen them and make subsequent removal more painless.

Seiffert's method. R. Seiffert, and later other authors, proposed a more gentle method of anterior nasal tamponade, which consisted of inflating a rubber balloon in the bleeding half (for example, a finger from a surgical glove tied to a metal or rubber tube with a locking device), which filled all the nasal passages and compressed the bleeding vessels. After 1-2 days, the air was released from the balloon, and if bleeding did not resume, it was removed.

If anterior nasal tamponade is ineffective, posterior nasal tamponade is performed.

Posterior nasal tamponade

Posterior nasal tamponade is often performed in emergency situations when a patient is bleeding profusely from the mouth and both halves of the nose, so the procedure requires certain skills from the doctor. The method was developed by J. Belloc (1732-1870), a prominent French surgeon who proposed a special curved tube for posterior nasal tamponade, inside which there is a long flexible mandrel with a button on the end. The tube with the mandrel is inserted through the nose to the choanae, and the mandrel is pushed into the mouth. Then the threads of the tampon are tied to the button of the mandrel and the tube together with the mandrel are removed from the nose together with the threads; when the threads are pulled, the tampon is inserted into the nasopharynx. Currently, a rubber Nelaton urological catheter is used instead of the Belloc tube. This method has survived to this day in a modified form.

For posterior nasal tamponade, a Nelaton #16 rubber catheter and a special nasopharyngeal tampon made of tightly packed parallelepiped-shaped gauze, tied crosswise with two strong thick silk threads 60 cm long, which form 4 ends after the tampon is made. The average tampon size for men is 2x3.7x4.4 cm, for women and adolescents 1.7x3x3.6 cm. An individual tampon size corresponds to two distal phalanges of the first fingers folded together. The nasopharyngeal tampon is soaked in Vaseline oil, and after squeezing out the latter, it is additionally soaked in an antibiotic solution.

After application anesthesia of the mucous membrane of the corresponding half of the nasal cavity, the catheter is inserted into it until its end appears in the pharynx from behind the soft palate. The end of the catheter is pulled out of the oral cavity with forceps, and two threads of the tampon are firmly tied to it, which are brought out through the nose with the help of the catheter. The tampon is inserted into the oral cavity by lightly pulling on the threads. Using the second finger of the left hand, the tampon is inserted behind the soft palate, and at the same time pulled by the threads with the right hand to the choanae. It is necessary to ensure that when inserting the tampon, the soft palate does not curl into the nasopharynx along with it, otherwise its necrosis may occur. After the nasopharyngeal tampon is tightly fixed to the openings of the choanae, the assistant holds the threads in a taut position, and the doctor performs anterior nasal tamponade according to V.I. Voyachek. However, anterior nasal tamponade may not be performed. In this case, the threads are fixed with three knots on a gauze anchor, tightly fixed to the nostrils. Two other threads coming out of the oral cavity (or one, if the second is cut off), in a relaxed position, are fixed with adhesive tape to the zygomatic region. These threads will later serve to remove the tampon, which is usually done after 1-3 days. If necessary, the tampon can be kept in the nasopharynx for another 2-3 days under the "cover" of antibiotics, but in this case the risk of complications from the sputum tube and middle ear increases.

The tampon is removed as follows. First, the anchor is removed by cutting the threads that hold it in place. Then, the insertion tampons are removed from the nasal cavity by irrigating it with a 3% hydrogen peroxide solution. After their removal, the loop tampon is soaked generously from the inside with hydrogen peroxide and held for some time to soak it and loosen the connection with the nasal mucosa. Then, the cavity of the insertion tampon is dried with a dry thin gauze tampon and irrigated with a 5% dicaine solution and a few drops of adrenaline hydrochloride solution (1:1000). After 5 minutes, continuing to soak the loop tampon with hydrogen peroxide, it is carefully removed. After making sure that the bleeding has not resumed (if the bleeding is minor, it is stopped with hydrogen peroxide, adrenaline solution, etc.), proceed to remove the nasopharyngeal tampon. In no case should you pull hard on the threads coming out of the oral cavity, as this can injure the soft palate. It is necessary, under visual control, to firmly grasp the thread hanging from the nasopharynx and pull it downwards, pull the tampon into the throat and quickly remove it.

In hemopathies of various etiologies, nasal tamponade and cauterization of bleeding vessels are often ineffective. In these cases, some authors recommend soaking tampons in horse or antidiphtheria serum, inserting gauze bags with a hemostatic sponge or fibrin film into the nasal cavity in combination with X-ray irradiation of the nose and spleen, once every three days, a total of 3 times. If the above-described techniques are ineffective, they resort to ligation of the external carotid artery and, in extreme cases, for vital indications, to ligation of the internal carotid artery, which is fraught with serious neurological complications (hemiplegia) and even death on the operating table.

Forecast

The prognosis is generally favorable.

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