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Treatment of nasal bleeding
Last reviewed: 23.04.2024
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The purpose of treatment of nasal bleeding
Stopping nosebleeds.
Drug medication for epistaxis
The most common cause of nasal bleeding in adults is arterial hypertension. Nasal bleeding most often occurs against a background of hypertensive crisis, which requires the appointment of antihypertensive therapy.
Recurrent nasal bleeding against the background of hypertension arises from the presence of chronic DVS-syndrome and the relative lack of plasma clotting factors caused by erythrocytosis - polycythemia (ie lack of coagulation factors per unit of blood cells), which leads to the formation of loose erythrocyte thrombi. Easily tearing away when removing tampons from the nasal cavity. To correct these disorders, intravenous drip administration of antiplatelet agents and agents providing hemodilution is necessary: actovegin (400 mg per 200 ml of 0.9% sodium chloride solution or 250 ml solution for infusion), pentoxifylline {100 mg per 200 ml of 0.9% sodium solution chloride), reomacrodex (200 ml). With persistent, recurrent nasal bleeding, a freshly frozen plasma and VIII coagulation factor can be administered. The introduction of a 5% solution of aminocaproic acid to this group of patients is contraindicated.
The main method of treatment of hemophilic hemorrhages is substitution therapy. It should be noted that the VIII factor is labile and practically not conserved in canned blood and native plasma. Therefore, for hemorrhage, only hemopreparations prepared with observance of such conditions under which preservation is provided are suitable. VIII.
The means of choice for the treatment of massive bleeding in patients with hemophilia is the drug etkakog alpha activated - recombinant VIIa clotting factor.
This drug in pharmacological doses is associated with a large amount of tissue factor, forming a complex of eptactor-tissue factor, which enhances the initial activation of the X factor. In addition, eptacog alpha in the presence of calcium ions and anionic phospholipids is able to activate the X factor on the surface of activated platelets by "bypassing" the coagulation cascade system, which makes it a universal haemostatic agent. Eptakog alfa acts only in the focus of bleeding and does not cause a systemic activation of the process of blood clotting. It is available in powder form for the preparation of injection solutions. 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 body weight. The drug is administered every 2 hours until the onset of clinical effect. Side effects: chills, headache, nausea, vomiting, weakness, changes in blood pressure, redness, itching. Contraindications Hypersensitivity to proteins of cows, mice, hamsters. In pregnancy, appointment for life. Cases of overdose and drug interaction are not indicated.
Treatment of thrombocytopenia should be strictly pathogenetic, among the acquired thrombocytopenia most often there are immune lesions that require the appointment of glucocorticoids. The daily dose of prednisolone is 1 mg / kg of body weight: it is divided into 3 divided doses. After the normalization of the number of platelets begin to reduce the dose of glucocorticoids up to the complete abolition of hormones.
The replacement therapy of thrombocytopenic hemorrhagic syndrome suggests a transfusion of platelet mass. Indications for transfusion of platelet mass are determined by the doctor based on the dynamics of the clinical picture. In the absence of spontaneous bleeding and the prospect of scheduled surgical interventions, a low, even, critical platelet level (less than 30x10 9 / L) does not serve as an indication for the appointment of a transfusion of platelet mass. If bleeding from the nose on the background of thrombocytopenia can not be stopped within 1 hour, 15-20 doses of platelet mass must be poured (I platelet dose contains 10 8 platelets) regardless of the number of platelets in the assay.
Aminocaproic acid in relatively small doses (0.2 g / kg or 8-12 g per adult patient per day) reduces bleeding in many disagregation thrombocytopathies, enhances the 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 platelet function and the inhibitory effect on fibrinolysis, nor by other effects-the normalizing effect on capillary permeability and resistance, inhibition of Hageman's factor and kallikrein bridge between XII and VII factors. This, apparently, explains the fact that aminocaproic acid reduces bleeding not only with qualitative platelet defects, but also with thrombocytopenia. Treatment with this drug is not indicated in the presence of macrogemgrany and DIC-syndrome. The drug is administered intravenously drip in 100 ml of 5-6% solution.
Similar to aminocaproic acid pharmacotherapeutic effects have cyclic amino acids: aminomethylbenzoic acid, tranexamic acid. These drugs significantly reduce the bleeding of the microcirculatory type (nasal, uterine bleeding). The most common was tranexamic acid. It is prescribed by mouth 500-1000 mg 4 times a day. In case of massive bleeding, 1000-2000 mg of the drug diluted in a 0.9% sodium chloride solution is injected intravenously. In the future, the dose and method of administration of the drug are determined by the clinical situation and laboratory parameters of the blood clotting process.
With thrombocytopathic and thrombocytopenic bleeding, ztamzilate is used. The drug has virtually no effect on the number and function of platelets, but increases the resistance of the membrane of endotheliocytes, thereby correcting secondary vasopathy against the background of platelet-derived hemostasis. Usually ztatzilat appoint or nominate inside 0.5 g 3-4 times a day; with massive nasal bleeding, intravenous fluid injection of 12.5% solution of 2 ml 2 times a day is prescribed, and an increase in the dose to 4 ml (3-4 times a day) is also permissible.
With nasal bleeding due to liver damage (including alcoholism) it is necessary to compensate for the lack of vitamin K. Deficiency of K-vitamin-dependent factors requires intensive therapy because of the rapid progression of the disease. A good affect is achieved by transfusion of the donor plasma or by intravenous administration of K-vitamin-dependent concentrate. Simultaneously, administration of menadione sodium bisulfite at a dose of 1-3 mg is prescribed. Treatment with this drug alone is not enough, since its effect on the level of K-vitamin-dependent factors begins in 10 hours, and their marked increase occurs in 16-24 hours, and the improvement in the prothrombin test is only 48-72 hours after the start of treatment. Therefore, ongoing bleeding always requires transfusion therapy.
In cases of massive bleeding caused by the use of indirect anticoagulants, plasma transfusions are produced in large amounts (up to 1.0-1.5 liters per day and 2-3 times per day), increase the sodium menadione bisulfite dose to 20-30 mg per day (in severe cases - up to 60 mg). The action of menadione sodium bisulfite is potentiated by prednisolone (up to 40 mg per day). Vitamin P, ascorbic acid and calcium preparations in these cases are not effective.
In case of bleeding caused by an overdose of heparin sodium, it is necessary to lower the dose of the latter or to skip 1-2 injections, and then to cancel it, gradually reducing the dose. Along with this, administration of a 1% solution of protamine sulfate intravenously at a dose of 0.5-1 mg for every 100 IU of sodium heparin can be prescribed.
When treating streptokinase or urokinase, nosebleeds may occur with a rapid drop in fibrinogen in the blood below 0.5-1.0 g / l. In these cases, with the cancellation of streptokinase, it is necessary to administer sodium heparin and an infusion with the replacement purpose of freshly frozen plasma, which contains a significant amount of plasminogen and antithrombin III. Such therapy requires a daily monitoring of the level of antithrombin III of the blood.
To improve haemostasis, calcium preparations are also used, since the presence of Ca 2+ ions is necessary for the conversion of prothrombin into thrombin, fibrin polymerization, and platelet aggregation and adhesion. However, calcium in the blood is contained in quantities sufficient for blood coagulation. Even with hypocalcemic convulsions, blood clotting and platelet aggregation are not violated. In this regard, the introduction of calcium salts does not affect the coagulation properties of blood, but reduces the permeability of the vascular wall.
[Methods of stopping nasal bleeding
First of all, it is necessary to calm the patient and release him from all the objects (necktie, belt, tight clothes) that tighten his neck and body, to give him a semi-sitting position. Then put a bubble on the back of his nose with ice or cold water, and at the feet of a heating pad. With minor nasal bleeding, a cotton swab with 3% hydrogen peroxide solution is injected into the nose of one of the nose halves from the anterior part of the nose, and the wings of the nose are compressed with fingers for several minutes. If the localization of the bleeding vessel is accurately established (after a dotted pulsating "fountain"), then after application of anesthesia with a 3-5% solution of dicaine in a mixture with several drops of adrenaline (1: 1000), this vessel is cauterized (cauterized) by the so-called lapis "pearl" electric cautery or YAG-niodim laser; it is also possible to use the method of cryodestruction. Produce the "pearl" as follows: on the tip of the aluminum wire, silver nitrate crystals are collected and gently heated them on the flame of the spirit lamp until melted and a round bead formed, which fuses closely to the end of the aluminum wire. Cautery is performed only on the side of the bleeding vessel, however, if necessary, this procedure and, on the other hand, to prevent the formation of perforation of the septum of the nose, it is carried out no earlier than 5-8 days after the first cauterization. After cauterization the patient should not strain, blow his nose and independently exert mechanical influence on the crusts formed on the septum. After cauterization 2-3 times a day, cotton swabs impregnated with 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 crest is an obstacle to stopping nasal bleeding, then a preliminary resection of the deformed part thereof is possible. Often, for the radical stop of nasal bleeding resort to detachment of the mucous membrane with perichondrium and cutting the vessels of the septum of the nose. If the presence of a bleeding polyp of the septum is determined, it is removed together with the underlying cartilage.
To stop nasal bleeding is often resorted to the anterior, posterior or combined tamponade of the nose.
Anterior tamponade of the nose is used in cases where the localization of the source of bleeding is obvious (anterior sections of the septum of the nose) and the stopping of nasal bleeding by simple methods is ineffective.
There are several ways of anterior tamponade of the nose. To carry out it, saturated gauze tampons saturated with vaseline oil and a broad-spectrum antibiotic with a width of 1-2 cm of different lengths (from 20 cm to 1 m), nasal mirrors of different lengths, nasal or auric roots, a solution of cocaine (10%) or dicaine (5 %) in a mixture with several drops of adrenaline chloride (1: 1000) for application anesthesia.
Method of Mikulich
A tampon 70-80 cm long in the direction of the choana is inserted into the nasal cavity and densely laid in the form of loops. The anterior end of the tampon is wound on a cotton wool forming an "anchor". Above impose a sling-like bandage. When the dressings are soaked with blood, they are replaced without removing the tampon. The disadvantage of this type of tamponade is that the posterior end of the tampon can penetrate into the pharynx and cause a vomiting reflex, and if it gets into the larynx, signs of its obstruction.
The way of Lawrence - Likhachev
It is an improved method of Mikulich. A thread is attached to the inner end of the tampon, which remains outside with the front end of the tampon and is attached to the anchor, thereby preventing slipping of the posterior end of the tampon into the pharynx. AG Likhachev improved the method of Lawrence in that he suggested pulling the back end of the tampon into the posterior parts of the nose and thereby not only preventing it from falling into the nasopharynx, but also tightening the tamponade of the nose in the posterior parts of the nose.
Method V.Voyachek
In one of the halves of the nose at its full depth, a loop swab is inserted, the ends of which remain outside. In the resulting loop, short (inserted) tampons are consistently inserted into the entire depth of the nasal cavity without collecting them into folds. Thus, several insert tampons are placed in the cavity, extending a loop swab and exerting pressure on the tissues of the inner nose. This method can be attributed to the most sparing, since the subsequent removal of the insertion tampons is not associated with their "detachment" from the tissues of the nose, but occurs in the environment of other tampons. Before removing the loop swab, 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 beyond the lateral end.
With the front tamponade of the nose, tampons are stored for 2-3 days, after which they are removed, if necessary, the tamponade is repeated. It is also possible to partially remove the tampon (or tampons under the method of Voyachek) to relax them and a more painless subsequent removal.
The way Seyffert. R. Seifert, and later other authors, suggested a more gentle method of anterior tamponade of the nose, consisting in that a rubber balloon was inflated 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 nasal passages and squeezed the bleeding vessels. After 1-2 days, air was released from the balloon, and if bleeding did not resume, it was removed.
If the front tamponade of the nose is ineffective, a posterior tamponade of the nose is performed.
Posterior tamponade of nose
Often, the back tamponade of the nose is carried out in emergency treatment of the patient with heavy bleeding from the mouth and both halves of the nose, so the procedure requires the doctor certain skills. The method was developed by J. Bellock (J.Bcollock, 1732-1870), a large French surgeon who proposed a special curved tube for the posterior tamponade of the nose, inside which is a long flexible mandrel with a button at the end. The tube with the mandrel is injected through the nose to the khoan, and the mandrone is pushed into the mouth. Then, to bind the mandrons, the threads of the tampon are attached and the tube, together with the mandrel, is extracted from the nose along with the threads; when pulling the threads, the tampon is inserted into the nasopharynx. Instead of the Belloc tube, a neural neural catheter is used. This method has been modified to the present day.
For the posterior tamponade of the nose, a nebulot 16 neat rubber catheter and a special nasopharyngeal tampon made of tightly packed gauze in the form of a parallelepiped, cross-wound with two strong thick silk threads 60 cm in length, forming the end of the tampon after the manufacture of the tampon. The average size of the tampon for men is 2x3.7x4.4 cm, for women and adolescents 1.7x3x3.6 cm. The individual size of the tampon corresponds to two folded distal phalanges of the first finger fingers. The nasopharyngeal swab is impregnated with vaseline oil, and after squeezing the latter, it is additionally impregnated with an antibiotic solution.
After the applica- tion anesthesia of the mucous membrane of the corresponding half of the nasal cavity, the catheter is driven into it until its end in the pharynx appears due to the soft palate. The end of the catheter is pulled out by the forceps from the oral cavity, and firmly bind to it two strings of the tampon, which, with the help of a catheter, are led out through the nose. With a gentle sip, a tampon is inserted into the mouth. With the help of the second finger of the left hand, a tampon is triggered by the soft sky, and simultaneously pulled by the right hand by the threads to the hoan. Thus it is necessary to watch, that at introduction of a tampon together with it or him the soft palate was not wrapped up in a nasopharynx, otherwise necrosis can come. After the nasopharyngeal tampon is tightly fixed to the holes of the khohan, the assistant holds the strings in a tensioned position, and the doctor holds the front tamponade of the nose, but to VI Voyachek. However, the anterior tamponade of the nose can not be carried out. In this case, the filaments are fixed with three knots on the gauze anchor, tightly fixed to the nostrils. The other two threads that come out of the mouth (or one, if the second one is cut off) are fixed in an unstrung position with an adhesive plaster to the cheekbone area. These threads will later serve to remove the tampon, which is usually carried out after 1-3 days. If necessary, the tampon can be stored in the nasopharynx for another 2-3 days under the "cover" of antibiotics, but in this case the risk of complications from the tube and middle ear increases.
Removal of the tampon is carried out as follows. First, remove the anchor by cutting the fixing threads. Then remove the insertion tampons from the nasal cavity, irrigating it with 3% hydrogen peroxide solution. After removing them, the loop swab from the inside is abundantly impregnated with hydrogen peroxide and held for a while to soak it and loosen the connection from the nasal mucosa. Then dry the dry gauze swab dry the cavity of the insertion swab and irrigate it with 5% solution of dicaine and several drops of the solution of adrenaline hydrochloride (1: 1000). After 5 minutes, while continuing to sweep the loop tampon with hydrogen peroxide, carefully remove it. Convinced that the bleeding was not resumed (with minor bleeding it is stopped with hydrogen peroxide, adrenaline solution, etc.), proceeding to remove the nasopharyngeal tampon. In no case can it be strongly pulled by the threads emerging from the oral cavity, since it is possible to injure the soft palate. It is necessary to firmly grasp the thread, hanging from the nasopharynx, under the control of the vision, and pull it down with a descending movement, pull the swab into the pharynx and quickly remove it.
With hemopathies of different etiologies, tamponing the nose and cauterizing the bleeding vessels are often ineffective. In these cases, some authors recommend impregnating tampons with horse or antidiphtheria serum, insert gauze sacs with a hemostatic sponge or fibrin film in combination with irradiation of the x-ray rays of the nose and spleen, once in three days, only 3 times. If the above methods are ineffective, they resort to dressing the external carotid artery and, in extreme cases, according to vital indications, to the bandaging of the internal carotid artery, which is fraught with serious neurologic complications (hemiplegia) and even death on the operating table.