Nose bleed

Epistaxis is a bleeding that occurs when the integrity of the vessels located in the nasal cavity, the paranasal sinuses, the nasopharynx, and the bleeding from the vessels of the cranial cavity are compromised in violation of the integrity of the upper wall of the nasal cavity.

[1], [2]

Causes of epistaxis

Often, nosebleeds are idiopathic. In older people, nosebleeds are usually due to degenerative changes in the arteries and hypertension. Local causes of nasal barking can be atrophic rhinitis, hereditary telangiectasia, tumors of the nose and sinuses. Of course, one should not forget that nosebleeds can be a manifestation of hemorrhagic diathesis.

Nasal hemorrhages of a local nature are most often due to anatomical features of the arterial plexus (plexus Kisselbachii) located in the anterior part of the septum of the nose, formed by terminal branching of the wedge-palatal, nasonephal, palatine ascending arteries.

These anatomical features include the mucosal fineness in the Kisselbach's plexus region, the local increase in arterial pressure, due to the fact that several arterial trunks are anastomosing in this area. Contributing factors are microtraumas of the nasal septum mucosa arising from the action of dust particles, aggressive gases contained in the inspired air, as well as mucosal atrophy and age-related changes. Often spontaneous bleeding of a local nature occurs after physical stress, general overheating of the body and during menstruation. The consequence of repeatedly occurring bleeding may be ulceration of the mucous membrane of the septum of the nose with the subsequent occurrence of the so-called creeping ulcer of the septum nasal (ulcus serpens septi nasi). Sometimes a so-called bleeding polyp of the septum of the nose, consisting of arteriovenous anastomoses and angiomatous tissue (but the histological structure - angioma or angiofibroma), which bleeds from the rhinitis, sneezing, and also spontaneously, forms in the anterior part of the septum. With a bleeding tumor, sometimes the presence of a leech or other blood-sucking parasites in the nasal cavity or back of the throat is mixed, which can enter the upper respiratory tract during bathing or drinking water from open water bodies.

Local bleeding should be differentiated from bleeding that occurs with malignant tumors, juvenile angiofibromas of the nasopharynx and some common diseases.

[3], [4], [5], [6]

Nasal bleeding of general origin

Often, nosebleeds, caused by common causes, are a very formidable complication, the outcome of which is not always favorable. Among the common causes, hypertensive syndrome (50%) is the most frequent, in which nosebleeds play a peculiar therapeutic role, "unloading" the vessels of the brain and preventing hemorrhagic complications in it. Nasal bleeding of hypertensive genesis is profuse, and often with untimely intervention can lead to significant hemorrhage and hypoxic collapse.

According to VB Trushin et al. (1999, 2000), VB Trushina (2001, 2004), the so-called autonomic dysfunction plays a great role in the development of nasal bleeding of a common genesis, in which there are disturbances in the vegetative regulation of the functions of the cardiovascular system, which is established by the study of indices of the vegetative Kerdo index in the orthostatic test. The latter can predict the recurrence of nasal bleeding. To prevent nasal bleeding in autonomic dysfunction, VB Trushin (2004) recommends transcranial action with a combined impulse and direct current in a ratio of 1: 2 at a frequency of 77 Hz with a pulse duration of 3.75 ms. With adequate or excessive sympathetic provision of an orthostatic test, a current of 0.1-0.2 mA is used; with adequate - within 5 minutes, with excess - 10 minutes. With insufficient sympathetic provision, the current is increased to 0.5 mA with a duration of exposure of up to 30 minutes.

Other causes of nasal bleeding of general nature include mitral valve stenosis, emphysema, liver cirrhosis, kidney and blood diseases, occupational intoxications, avitaminosis C, Osler's disease (multiple hereditary telangiectasias of the skin and mucous membranes, localized mainly on the lips and nasal mucosa, frequent nosebleeds, often hemoptysis, bloody vomiting, usually develops secondary post-amorrhagic anemia, often hepatomegaly with subsequent cirrhosis of the liver), agra ulotsitoz. Syndrome (full or partial disappearance of the granular blood leukocytes; genesis - mielotoksichssky and immune), etc. Often, nasal bleeding caused by common causes are accompanied by hemorrhage in the internal organs, subcutaneous fat or other areas.

Nasal bleeding of traumatic origin

This type of bleeding accompanies nasal injuries in 90% of cases and may range from insignificant to profuse, requiring emergency intervention. However, in contrast to nasal bleeding of a "general nature", which practically do not lend itself to radical treatment, this type of nosebleeds is often stopped by the simplest methods. Bleeding from the nose can be observed with fractures of the base of the skull, and in particular for violations of the integrity of the trellis plate. In these cases, nasal bleeding is often accompanied by a nasal cerebrospinal fluid.

The tactics of the doctor with nasal bleeding of traumatic origin is as follows. First of all, it is necessary to assess the nature of the injury (injury, injury, the presence or absence of brain trauma, the general condition of the victim), the intensity of bleeding (mild, moderate, profuse). Then, appropriate measures are taken to provide immediate assistance to the victim, consisting primarily of stopping bleeding and, if necessary, combating traumatic shock. In case of a nasal injury, surgical treatment of a wound with a primary rhinoplasty and a tamponade of the nose is performed. At the same time, to prevent purulent complications, antibiotics of a wide spectrum of action and appropriate haemostatic drugs are prescribed.

Epidemiology of epistaxis

Blood from the nose according to the frequency of occurrence ranks first among spontaneous bleeding. The share of nasal bleeding ranges from 3 to 14.3% in the overall structure of hospitalized patients in an ENT hospital and is 20.5% hospitalized for emergency indications.

Most nasal bleeding occurs from vessels located on the nasal septum. In relatively young people (younger than 35 years), nosebleeds can occur from a vein located behind a columella (septum) of the vestibule of the nose. In the elderly, epistaxis is often an arterial bleeding from the Little area, where the anterior articular artery meets, the septal branches of the main palatine artery, the upper labial artery and the large palatine artery.

[7]

Treatment of nasal bleeding

First of all, it is necessary to fulfill three conditions: in time to recognize the shock condition and make if necessary a blood transfusion, identify the source of bleeding and stop the bleeding. In the elderly, nosebleeds often cause a shock, which can be fatal. If the patient has signs of shock, he must be hospitalized and blood transfusion started. Usually, people with nasal bleeding are seated on a chair (this reduces venous pressure) and in this position is assisted. If the patient is in a shock state, it should be laid to maximize the perfusion of the brain. If there is no shock or it was managed to stop, then the main medical attention should be directed to fighting with bleeding. First of all, squeeze the nostril with your thumb and index finger and hold it for at least 10 minutes; it is advisable to place an ice bag on the back of the nose and ask the patient to clench his teeth, for example, a stopper from a bottle (wine) - this may be enough to stop nosebleeds. If the above method stops the nosebleeds, you should remove the blood clot from the nose with Luke's tweezers or suction. The nasal mucosa needs to be treated with an aerosol of 2.5-10% cocaine solution - it will anesthetize it and reduce the flow of blood to it due to the reduction of blood vessels. Any bleeding point should be burned.

If the bleeding point can not be detected, and the nosebleeds continue, tamp the nose with a strip of gauze 1 or 2.5 cm wide impregnated with paraffin and iodoform paste. The tampon is inserted with special forceps (Tilley). After you hold the front tamponade of the nose, the bleeding stops and the patient can be released home. The tampon should not be removed within 3 days. If the nosebleeds continue, despite the anterior tamponade, a posterior tamponade of the nose is necessary. It is performed as follows: after removal of the front tampon from the nose through the nostril, the Foley catheter is carried out, while its 30-ml balloon is located in the nasopharyngeal space, then the balloon is inflated and the catheter is pulled anteriorly. After that, the front of the nose is plugged. The posterior tamponade of the nose is carried out for 24 hours, during which the patient must be in the hospital. If the nosebleeds still continue, you need to re-tampon the nose, but this is a very painful procedure, and usually it will demoralize the patient. In rare cases it is necessary to resort to ligation of the arteries [the approach to the maxillary artery with bleeding from the large palatine artery and the main palatine arteries is carried out through the maxillary (gimorovu) sinus; to the front latticed artery - through the orbit]. To stop the ongoing nasal bleeding, sometimes you have to ligate the external carotid artery.

Code for ICD-10

R04.0 Epistaxis

[8], [9], [10]