Nosebleeds (Epistaxis)

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Nosebleeds (Epistaxis)

Bleeding from the nose (epistaxis) is usually a symptom of a disease, it occurs relatively often and can be due to various local or general causes. So, trying to clear a stuffy nose with rhinitis and other diseases, they often injure the mucous membrane of the nasal cavity with fingernails, then excoriation forms at this place, nosebleeds and ulceration appear. Injuries can be accompanied not only by nosebleeds, but also by the leakage of cerebrospinal fluid (with an injury to the anterior skull).

Bleeding from the nose can be a symptom of swelling in the nose (angioma) or paranasal sinuses, foreign bodies. Infectious diseases (influenza, diphtheria, scarlet fever, measles, typhoid fever), blood diseases (leukemia, hemophilia, chlorosis, anemia, purpura, etc.), grief, sepsis, nephritis, diseases of the cardiovascular system (heart disease) lead to nosebleeds. , circulatory failure, etc.).

Trying to clear a stuffy nose with rhinitis, people often injure the mucous membrane of the nasal cavity with fingernails, nosebleeds (bleeding from the nose) appear.

Anything that causes an increase in blood pressure can also contribute to the appearance of nosebleeds (physical and mental stress, emotions). Epistaxis (nosebleeds) sometimes occurs during puberty (in girls over 12 years old, vicarious nosebleeds are possible instead of menstruation), with congestion due to tight-fitting clothing, low atmospheric pressure (in the highlands). Epistaxis (nosebleeds) in children can be masked. If the child swallows blood, bloody vomiting is possible.

Repeated nosebleeds (nosebleeds) for no apparent reason can lead to complications, more often to anemia. In such cases, it is necessary to exclude the root cause: blood diseases, hemorrhagic diathesis (Verlhof's disease, etc.), or juvenile hypertension. The cavernous vessels of the nasal cavity in children reach full development only at the age of 5-6 years. Therefore, in early childhood, nosebleeds are rare, in older children - more often, during puberty - most often.

Boys have nosebleeds (nosebleeds) more often than girls. With diseases of the circulatory system and kidneys, there is arterial bleeding, with hemorrhagic diathesis - capillary ("sieve leakage"), with inflammatory diseases of the nose - venous. In 96% of cases, nosebleeds come from the anteroinferior part of the nasal septum (Kisselbach zone), which is explained by the significant development of the vasculature here, and also by the fact that it is this part of the nose that is most often injured.

When the nose injury (contusion, dislocation of the cartilage of the nasal septum, nasal bone fracture) occurs nosebleeds.

Treatment of nosebleeds (epistaxis)

To eliminate nosebleeds, the patient's head is given an elevated position, you need to unbutton the collar, put a warm heating pad on the legs, and cold on the nose. For 3-5 minutes, they are forced to inhale through the nose, and exhale through the mouth, conduct oxygen therapy (inhalation of oxygen through the nose from an oxygen pillow). Inexcessive nosebleeds can be stopped by pressing the wing of the corresponding half of the nose with a finger against the nasal septum. Sometimes a cotton ball with hydrogen peroxide, S-aminocaproic acid, adrenaline, thrombin is injected into the corresponding half of the nose. If nosebleeds are threatening, more effective measures are needed, but for this, it is important to find out from which half of the nose the bleeding has occurred.

Often (in case of injury) blood appears from both halves of the nose. To find the site of nosebleeds (nosebleeds), the child's head is lowered slightly and asked to blow his nose. Then you should wipe the entrance to the nose and see from which half of the nose the blood is poured into the tray. A slight downward tilt of the head prevents blood from flowing into the pharynx and has another advantage: it stops swallowing and gagging caused by blood entering the pharynx. Having cleared the nasal passages from blood clots by blowing the nose, examine the nose (preferably with a nasal mirror). If no nosebleed is found in a typical location (Kisselbach's zone), it should be assumed that it is in the posterior portions of the nose. The sources of bleeding are easier to determine in older children with wide nasal passages and after the use of solutions of cocaine (5% solution) and adrenaline (1: 1000). Examine tuberculum septi on the nasal septum, where there is an accumulation of cavernous tissue.

Having established the place of nosebleeds, moxibustion is performed using various cauterizing agents (trichloroacetic acid, 10% silver nitrate solution), electrocaustics or surgical diathermy. These funds differ in the degree and depth of cauterization. Alum, tannin, zinc, silver nitrate have a weak cauterizing property, and a superficial scab is formed. Chromic acid, electrocautery, and surgical diathermy cause deep eschar. Cauterization can be performed immediately from 2 opposite sides of the nasal septum, it is only necessary that the places of cauterization are not opposite each other. Excess acid on the mucous membrane is neutralized with a 2% sodium bicarbonate solution. Subsequently, a scar forms at the site of cauterization.

Epistaxis (nosebleeds) may be from post-traumatic carotid-cavernous anastomosis seen on CT angiography of the cerebral vessels.

Since in some cases, after the usual cauterization, the resumption of nosebleeds is possible, recently the classical technique has been changed: instead of cauterizing the bleeding place, a "halo" is made around it, after which the bleeding usually does not resume. This contributes to the obliteration of blood vessels at the approaches to the bleeding site.

In case of failure of the specified treatment of bleeding from the nose, an anterior tamponade is performed. Tampons are left for 24 hours, then removed, if bleeding continues, the nasal cavity is tamponed again. When bleeding from the posterior parts of the nasal cavity, the anterior tamponade may be unsuccessful. In rare cases, back tamponade is done (after it, angina, middle ear inflammation, sinusitis may occur). A combination of anterior and posterior tamponade is a more reliable way to temporarily stop bleeding. To facilitate the removal of the tampon, it is pre-impregnated with some lubricating or hemostatic substance. You can moisten a tampon with a 3% solution of hydrogen peroxide, plasma, blood serum, inject it with thrombin, a hemostatic sponge.

For tamponade of the nose with bleeding from the nose, tampons from the peritoneum of cattle, as well as pneumatic tampons (balloons) of various designs are proposed. So, a rubber can is inserted into the nasal cavity and the air is injected into it; swelling, it presses on the nasal mucosa, squeezing the vessels.

With a hemostatic purpose, a 5-10% solution of calcium chloride, 1% solution of Z-aminocaproic acid, 1% solution of Vicasol are prescribed orally or intravenously. With severe nosebleeds and large blood loss, blood is transfused intravenously. A good effect is achieved with direct blood transfusion, especially with hemophilia or Werlhof's disease. For hemophilia, antihemophilic globulin and plasma are prescribed. With exsanguination, the introduction of physiological and blood substituting solutions is indicated.

When stopping nosebleeds, it is necessary to ensure that blood does not flow down the back of the pharynx (this indicates the failure of the methods used).

With traumatic brain injury (concussion, cerebral contusion), the appearance of epistaxis with an admixture of cerebrospinal fluid (CSF) is possible.

What should be the nutrition for a patient with a tendency to frequent nosebleeds? With significant nosebleeds, you should temporarily refrain from eating. Do not eat hot food and especially drink strong tea, coffee, cocoa, as this can increase blood pressure and expand the lumen of blood vessels. Recommended food rich in proteins (taking into account sensitivity to them): cottage cheese, slightly fried liver, concentrated chicken broth. Fresh vegetables, fruits, juices, vitamins are needed.

Cryoexposure is used for various etiology of nosebleeds (with recurrent nosebleeds of unclear etiology) and is performed both during bleeding and in a period free from it (with habitual nosebleeds). The source of bleeding in the nose is easier to identify with wide nasal passages and after lubricating the nasal mucosa with a 5% solution of cocaine and adrenaline (1: 1000). For cryo-exposure, a cryoapplicator with a vapor-liquid circulation of nitrogen is used and the “snow” of carbonic acid (-79 ° C) is used - an oval spoon (4x6 mm) is taken from a polymer material and a lump of “snow” is taken and applied to the bleeding area.

Exposure to a cryoapplicator and cryoprobes is performed by a two-cycle method. More often than not the place of nosebleeds (nosebleeds) is frozen, but the area around it is the "halo". Cryotherapy is sometimes performed immediately from 2 opposite sides of the nasal septum, however, the areas of freezing should not be opposite each other. The exposure of freezing with a cryoapplicator is on average 30-120 s, with a cryoprobe and "snow" of carbonic acid - 15-30 s. In some cases, without waiting for the frozen area to thaw, nasal tamponade is performed. This combined technique is more effective.

In the process of cryotherapy, at first, there is blanching of the nasal mucosa in the area of freezing; a linear depression in the form of a whitish-snow strip remains at the site of the direct application of cold. After 3-4 minutes, the appearance and color of the mucous membrane are completely restored, however, within 1 day, edema and hyperemia develop. In the future, the area of the nasal mucosa, subjected to cryoinfluence, becomes yellowish, then gradually necrotic.

Surgical measures also recommend exfoliation of the nasal mucosa along with the perichondrium, ligation of the adducting arteries throughout. If the nosebleeds do not stop, the blood vessels are ligated: the external carotid (one or both) and the internal jaw arteries. An operating microscope can be used to ligate the internal jaw artery, which improves the visibility and illumination of the operating field. To stop the pulsating bleeding on the eve of the nose, sometimes the vessel is ligated from the side of the hard palate in the area of the incisal opening. If after the ligation of the vessel the bleeding does not stop, the ligation is performed on the other side.

Sometimes, with injuries, nosebleeds are combined with liquorrhea. An extreme measure to stop nosebleeds is to ligate both external carotid arteries.

For nosebleeds in adolescents and adults, medical intervention is also necessary. In the overwhelming majority of cases, it is not difficult to stop nosebleeds, but not everyone knows the simple techniques that are used in such situations. With rare exceptions, the bleeding site is located on the anteroinferior segment of the cartilaginous part of the nasal septum, and its place in good lighting can be determined even without a nasal speculum, by lifting and moving the tip of the nose. Most often (in 85-95% of cases) it is caused by a superficial excoriation of the mucous membrane.

The doctor needs to figure out which side of the nose the nosebleeds are from (nosebleeds). Often, blood flows from both halves of the nose, not because there are lesions on both sides of the nasal septum, but simply because blood flows over the upper surface of the soft palate from one side of the nose to the other. How to find a bleeding place, what should be the position of the head with nosebleeds, was discussed above.

A conically rolled tampon made of cotton wool or antiseptic gauze is introduced into the bleeding zone, and the patient presses the wing of the nose against the nasal septum. The tampon should not be too thick to fit not only in the front of the nose but also to some extent inside the nose. You can insert a nasal mirror and, using a reflector, insert a short tampon using nasal forceps up to the bone part between the inferior concha and the septum. An inexperienced doctor should not decide on other measures and deeper packing, as he can injure the nasal mucosa. Also, deep tamponade does not directly affect the site of nosebleeds, but can only lead to complications.

The tampon, even if it is soaked through with blood, does not need to be removed (at the same time, the formed clots can be removed); only if after a few minutes the profuse bleeding has not decreased, the tampon is replaced with a new one.

The infusion of even indifferent fluids into the nose is absolutely inappropriate, since it can cause swallowing movements and cause the removal of already formed blood clots.

The use of hemostatic dressings impregnated with special drugs is not only unnecessary but also harmful since these agents act in a cauterizing manner and cause suppuration. Concentrated silver (which is often abused) should be especially avoided - it necrotic tissue and can contribute to the formation of pyemic embolism. You can moisten the swabs with hydrogen peroxide for a good but short-term effect.

A patient with nosebleeds can overcome the urge to sneeze by firmly pressing the thumb against the part of the hard palate lying directly behind the upper incisors. For this purpose, Americans energetically press the end of the index finger in the corner between the upper lip and the nasal bridge. If the urge to sneeze persists for a long time, anesthetics have to be used.

A well-executed tamponade in the front stops any bleeding. Nasal tamponade through the nasopharyngeal space is considered by many to be unnecessary and even dangerous, since the inserted tube can cause damage, especially with insufficient experience of the doctor or abrupt manipulations.

Belokkovskaya tamponade is burdensome in all respects, but especially when the size of the tampon is not suitable. Too small a tampon can be pushed into the nose and cause severe pain; strongly embedded in the nasal passage, it is difficult to extract through the nasopharynx and mouth. If it is too large, then it clogs the other half of the nose, presses on the tube roll and closes it, which leads to complications. Delayed discharge can cause suppuration of the middle ear (the tampon is inserted for 24 hours or more).

Belokkovskaya tamponade is appropriate only with a source of bleeding in the nasopharyngeal space (this happens only after local surgery).

If the doctor considers the use of the specified tamponade inevitable, he should choose not a hard tube, but an elastic catheter or a soft rubber tube. It is passed through the bleeding nasal cavity until the end appears on the back of the pharynx, then it is pulled forward with forceps.

A prepared tampon is tied to a rubber tube and pulled into the nasopharyngeal space. It is advisable to help the movement of the tampon with your finger from the side of the mouth and press it close to the choans, i.e. pull with the hand outside. Do not force the tampon on, as this causes pain and makes it difficult to remove. A swab (the size of a patient's little finger) may consist of folded strips of gauze soaked in iodoform ointment or synthomycin emulsion. On one side of the tampon, a strong silk thread is fixed, on the other - 2 ends of the threads, intended for attaching it to a rubber tube, followed by tightening from back to front through the nose.

Between the 2 strings held by the helper, you can insert a smaller swab in front and tie. One of the threads goes through the mouth from the outside and is attached to the face with a plaster; it is designed to relieve the pressure of the tampon and, with weak tension, does not irritate the soft palate, difficulty in swallowing, swelling of the tongue (all this is possible if the thread is too tightly pulled). A rhinologist can remove a tampon without using this thread, pushing it from front to back with a solid probe. However, practitioners should not use this technique but maybe advised to attach another thread to the tampon and use it to remove the tampon by pulling it back to front. At the same time, the left index finger should protect the soft palate from thread penetration.

The protein tampon should not be left for more than 1-2 days, since in and around it, despite the presence of iodoform, decomposition of blood and secretions occurs and the surrounding tissues are easily exposed to inflammation and infection. As noted above, this is especially dangerous for the ear.

By monitoring your body temperature, you can determine if the tampon should be removed or if it can still be left. The front swab is removed very carefully, in severe cases - possibly later (after 1-2 days). It is not recommended to soften it with warm water, as at the same time blood clots may soften, and bleeding will resume. The formed crusts should not be removed immediately; you need to blow your nose carefully.

Recurrent nosebleeds allow one to suspect a general disease (kidney disease, arteriosclerosis, liver cirrhosis, leukemia, sepsis, hemophilia, etc.), but even in this case, they are localized on the front of the nasal septum, and not in the inner parts of the nose.

The excess of chromic acid is neutralized with a 2% sodium bicarbonate solution, which is moistened with a cotton swab applied to the site of cauterization (chromic acid has a cauterizing force if it is dark red, but if the drop turns black or turns green, this effect is absent). Cauterization is performed only after the bleeding has stopped, otherwise, the formed crust will be washed off with a fresh stream of blood. A loose cotton swab inserted after cauterization protects the formed scab from mechanical damage.

The excess of chromic acid is neutralized with a 2% sodium bicarbonate solution, which is moistened with a cotton swab applied to the site of cauterization (chromic acid has a cauterizing force if it is dark red, but if the drop turns black or turns green, this effect is absent). Cauterization is performed only after the bleeding has stopped, otherwise, the formed crust will be washed off with a fresh stream of blood. A loose cotton swab inserted after cauterization protects the formed scab from mechanical damage.

All of the above measures can be applied for bleeding due to bruising, blunt blow to the nose, when the mucous membrane may rupture.

Very rarely, bleeding occurs with neoplasms in the nasal cavity; polyps, contrary to popular belief, do not tend to bleed. The doctor should draw the attention of the operating surgeon to the bleeding after endonasal surgery as soon as possible, limiting himself to the measures recommended above in case of spontaneous bleeding and being careful to remove the tampon inserted after the operation. Only in the most extreme case, when all measures were in vain, and the place of bleeding is presumably located in the deeper parts of the nasal cavity (neoplasms, wounds, surgical wounds, etc.), a doctor who owns the appropriate technique of therapeutic techniques can perform a deeper tamponade using a nasal speculum and nasal forceps. At the same time, since the nose is not a closed cavity (open posteriorly), it is impossible to insert and gradually push the end of the long gauze strip forward until the nasal passage is filled. Usually, a tampon soaked in blood and secretion, after a while, moves in the pharynx and causes nausea, which again can cause bleeding that is difficult to stop.

The easiest way to tamponade for nosebleeds is that a gauze strip folded in several layers (preferably with a hemostatic agent) is inserted as deeply as possible and without any force along the nasal bottom using a forceps that grabs the tampon at its outer end, and not along its entire length.

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