Recurrent nosebleeds microbial 10. Nosebleeds: symptoms and causes. If there is a lot of bleeding from the nose

Nosebleed is the discharge of blood from the deepening of the nose through the nostrils. Occurs in more than half of the population, frequent nosebleeds usually occur before the age of 10 and over 50. And they are found in the male sex, in comparison with the female, much more often. Sometimes blood is secreted not outward, but into the oral cavity, and then enters the stomach. More often occurs at night.

Nosebleeds - Causes

Almost every person has experienced nosebleeds during their lifetime. But not everyone knows why it happens. For microbial 10 nosebleeds, the code R04.0 was assigned. Often a person does not feel pain or discomfort. For the purpose of prevention, it is necessary to establish provoking factors. The causes of nosebleeds (epistaxis) are usually divided into local and general.

Local provoking factors include:

Injury - injuries of the nasal mucosa, provoked by the ingress of a foreign object, injuries after surgery
diseases that provoke a glut of blood secretions of the nasal mucosa - acute and chronic rhinitis, sinusitis, adenoids
neoplasms - cancer, angioma in the deepening of the nose
deviations of a dystrophic nature in the nasal mucosa - deviations of the nasal septum from the midline

Common reasons include:

cardiovascular diseases - heart disease, atherosclerosis
elevated body temperature due to the presence of an acute infectious disease, as a result of overheating or sunstroke
the presence of pathologies that cause barometric pressure (its drops) - a syndrome that occurs in the practice of pilots, climbers or divers
hormonal imbalance (hemorrhage during pregnancy, puberty)
blood clotting changes
menstrual disorders (vicarious nosebleed)

Symptoms

The main signs of nosebleeds will help establish the diagnosis - the discharge of blood secretions from the nostrils outward or through the nasopharynx into the oral cavity. If the hemorrhage occurred at night, during sleep, you can swallow the secretions of blood. Therefore, in vomit or feces, blood discharge can be detected. If the syndrome is caused by the presence of a disease, the patient is diagnosed with the symptoms of the disease that provoked the disease.

If the patient has profuse nosebleeds, symptoms of anemia (headache, weakness, pale skin) may occur. The severity of symptoms depends on the type of bleeding, the volume of blood loss, the age and gender of the patient.

A person may experience the following symptoms:

complaints of general malaise
noise or ringing in the ears
headache and dizziness
pale skin
heart beats faster
thirst

In pregnant women, epistaxis is a common occurrence due to a lack of vitamin K. If the syndrome accompanies headache or dizziness, it may be triggered by an increase in blood pressure. In this case, you should immediately consult a doctor.

Diagnostics

Due to the fact that the symptoms are pronounced, it is not difficult to make a diagnosis of "nosebleeds". The doctor fills in the case history, in which the disease is assigned the code R04.0 according to microbial 10. The medical history includes complaints of the patient, symptoms, data about the patient. Due to the fact that various diseases can cause epistaxis, the medical history is carefully studied by the doctor, it turns out why the syndrome arose.

If the doctor suspects that the patient has diseases of the blood or the cardiovascular system, the patient is prescribed a blood test from a finger, a coagulogram, and blood pressure is measured.

Types of bleeding

Epistaxis, depending on the place of occurrence, can be:

front
rear

Anterior nosebleeds are usually characterized by low intensity and are not dangerous to human health. Anterior nosebleeds can stop without outside intervention (if a person does not have blood and vascular diseases) or using the simplest first aid measures.

Posterior nosebleeds, on the contrary, are characterized by a large volume of hemorrhage and can harm human health. The patient may complain of headache, malaise. In 5-10 percent, blood flows from the branches of large blood arteries in the posterior or middle parts of the nasal cavity. In rare cases, it is possible to stop the syndrome on your own. That is why timely provision of emergency care and the use of special methods to stop it is required.

Degrees of blood loss

Depending on how much blood has flowed out of the nasal cavity, several degrees are distinguished:

Minor stage - stands out from a couple of drops to a couple of milliliters of blood secretions. It does not threaten the health and life of a person, the patient does not feel pain or discomfort. Symptoms are mild. The only negative consequence may be fright or fainting in children.
Mild degree - a person loses no more than 700 ml of blood. A person may experience the following symptoms - dizziness, pallor of the skin, increased heart rate.
The average degree - a person loses blood from 1000 to 1400 ml. Symptoms are more pronounced - headache, tinnitus, general malaise, thirst.
Severe stage - it is characterized by severe nosebleeds. The amount of leaked blood is more than 20% of all blood moving through the vessels. Massive bleeding syndrome causes hemorrhagic shock. Frequent nosebleeds increase the risk of anemia.

When help is needed

In what cases is medical assistance required:

great loss of blood
hemorrhage provoked by trauma to the nasal cavity
fever and headache
hemorrhage does not stop for a long time

First of all, don't panic. Having discovered the symptoms of nosebleeds, it is necessary to provide a person with peace, help to take a half-sitting position, throwing his head back a little. If a person is unconscious, it is necessary to lay him on his back, turning his head to the side and transport him to the hospital.

Blowing your nose is strictly prohibited, as this process does not allow the damaged vessel to clog with blood clots and eliminate hemorrhage. Cold is applied to the bridge of the nose (a container with ice). This will help narrow the vessels and stop epistaxis.

If nasal bleeding is not too abundant, it is necessary to carefully press the wings of the nose against the nasal septum and continue to hold for 5-10 minutes until the syndrome stops. In case of severe hemorrhage, if it does not stop within 10 minutes, a cotton wool turunda is inserted into the nostril, after wetting it in a 3% hydrogen peroxide solution. If epistaxis has caused overheating, the victim should be moved to the shade.

Preventive measures are aimed at:

strengthening the walls of blood vessels
providing indoor air humidity
daily diet should include minerals and vitamins
prevention of injury to the nasal cavity

Nose bleed- bleeding from the nasal cavity or nasopharynx.

Code according to the international classification of diseases ICD-10:

R04.0

Anterior nosebleeds often arise from the anterior parts of the nasal cavity, usually from the Kiesselbach place (a section of the mucous membrane of the nasal septum, located 1 cm beyond the entrance to the nose, containing a large number of capillaries). The second most common localization is the anterior sections of the inferior turbinate.

Posterior nosebleeds originate from the posterior nasal cavity or nasopharynx—usually from the inferior turbinate or fornix.

Dominant age- up to 10 and after 50 years.

Causes

Etiology. Idiopathic bleeding (most common). Traumatic bleeding - inaccurate cleansing of the nasal cavity (epistaxis digitorum), dryness of the nasal mucosa, foreign body, fractures of the nasal bones. Upper respiratory tract infections - acute and chronic rhinitis, acute and chronic sinusitis. Vascular anomalies - sclerotic age-related changes in blood vessels, hereditary hemorrhagic telangiectasia, arteriovenous aneurysms. Neoplasms (including tumors of the paranasal sinuses). Arterial hypertension (usually in combination with other causes). The pathology of the blood coagulation system is congenital (for example, hemophilia), therapeutic or caused by side effects of drugs, leukemia, platelet dysfunction and other blood pathologies. Curvature of the septum (one side is more susceptible to drying air). Endometriosis (nasal location of endometriomas).

Symptoms (signs)

clinical picture. Usually external nosebleeds. Posterior bleeding may present with hemoptysis, nausea, vomiting of blood, or chalking.

Diagnostics

Laboratory research. KLA - signs of hypovolemic shock with massive bleeding or anemia.

Special Studies shown with an atypical picture. X-ray of the paranasal sinuses. Angiography (rare).

Differential diagnosis. Epistaxis is not an independent nosological form, but a symptom. Less than 10% of cases are due to neoplasms or pathology of the blood coagulation system.

Treatment

TREATMENT

Mode. Usually outpatient. With massive bleeding, hospitalization is indicated. Elderly and senile patients with posterior epistaxis and tamponade or balloon systems usually require hospitalization. Bed rest, elevated position of the head end of the bed at an angle of 45-90 °.

Diet. Exclusion of alcoholic and hot drinks.

Tactics of conducting. With hemorrhagic shock, resuscitation measures are indicated. Sedatives, analgesics, antihypertensives and hemostatic agents - according to indications. The source of bleeding should be determined.. It is necessary to remove liquid blood from the nasal cavity (by suction) and clots (using tweezers or by asking the patient to blow his nose).. To determine the location, suspicious areas should be blotted with a wet swab. The presence of several sources indicates a systemic disease. these two areas have different sources of blood supply, which is important in ligation of vessels. Determination of localization can be difficult with bilateral bleeding. More often, bleeding is unilateral, and the appearance of blood in the opposite half of the nasal cavity is associated with the following factors. back bleeding.

Anterior bleeding.. A swab moistened with a solution of a vasoconstrictor and a local anesthetic should be placed in the nasal cavity, and the wings of the nose should be pressed for 5-10 minutes. Then the swab should be removed and the vessels examined. Cauterization with silver nitrate solution for 30 seconds is shown (it is necessary to press it quite tightly) .. In addition to silver nitrate, it is possible to use chromic or 25% trichloroacetic acid. In case of damage to large vessels, it is preferable to perform electrocoagulation. Unsystematic coagulation of large areas should be avoided. If the above measures fail, a second dose of anesthetic and anterior nasal tamponade are indicated using a narrow strip of gauze (1-2 cm wide) soaked in vaseline oil to prevent the tampon from drying out. Narrow-jawed tweezers and a nasal speculum should be used to hold the gauze strip tightly. Laying must be carried out in layers, and each subsequent layer must overlap the previous one (serpentine).

Rear bleeding.. Traditional posterior tamponade of the nose or the use of various balloon systems. side and output through the mouth. The catheter is pulled out of the nose, which causes the tampon to be pressed against the choana behind the soft palate. The second thread hangs down from the nasopharynx and subsequently serves to remove the tampon... In any case, the posterior tamponade is supplemented by the anterior tamponade. halves of the nasal cavity ... The usual balloon system is represented by a small posterior (10 cm3) and a large anterior (30 cm3) balloons ... After local anesthesia, the tube is inserted into the affected half of the nasal cavity and advanced into the naso-pharynx as a nasogastric tube. Then the posterior balloon is inflated with air or water and advanced in the opposite direction until it is pressed against the choanae. After that, the anterior balloon is inflated (see Complications) ... A very effective method is the use of a catheter - a Foley balloon with sizes from 10 to 14 on the Charrier scale. The catheter is passed through the nasal passage into the nasopharynx or upper oropharynx. It is necessary to make sure that the catheter is not inserted into the lower parts of the pharynx, for which the oral cavity is examined. The balloon is inflated. Pass the catheter back until it covers the area of bleeding. Anterior tamponade of the nose is performed according to the method discussed above. A clamp is applied to the end of the catheter near the nostril. A gauze pad is placed under the clamp. The end of the catheter is passed behind the ear and secured.

If the above measures are ineffective (heavy bleeding), the following actions are indicated. To achieve adequate compression, bilateral tamponade is sometimes necessary. . By subsequent inflation of the balloon, the desired pressure of the tampon on the roof of the nasal cavity is achieved. Severe bleeding requires surgical ligation of the arteries. Ideally, it should be performed after a preliminary examination of the nasal cavity and determination of the location of bleeding. An alternative method of treatment is selective angiographic embolization of arteries. The need for blood transfusion depends on the Hb content, the CVP value, and vital signs.

Drug therapy. To narrow the vessels of the nasal mucosa - phenylephrine 0.25% r - r, xylometazoline (0.1% r - r), epinephrine (0.1% r - r). Local anesthetics - lidocaine aerosol, lidocaine gel (2%), lidocaine rr (4%), lidocaine glue (2%). Some clinicians suggest the use of systemic antibiotics and decongestants to prevent the development of sinusitis with tamponade and the use of balloon systems, if there is a need to maintain tamponade for more than 24-48 hours. With significant blood loss, replenishment of iron deficiency.

observation. Monitoring of hemodynamics according to indications. Tampons and balloon systems are removed after 24-36 hours*

Complications. Sinusitis. Dual balloon systems can move towards the pharynx, and if the anterior balloon fails, obstruction of the airway by the posterior balloon can occur. Prevention - applying a clamp to the end of the catheter directly near the nostril after inflating the balloons. Hematoma or abscess of the nasal septum due to trauma during tamponing. Perforation of the septum with excessive coagulation of the mucous membrane. Mucosal necrosis due to excessive pressure during anterior or posterior tamponade, balloon inflation (bedsores with subsequent infection). Deformation of the outer part of the nose. Lidocaine intoxication. Vegetative-vascular attacks during packing (sneezing, coughing, lacrimation).

Associated pathology. In elderly patients - arterial hypertension, atherosclerosis and conditions characterized by a decrease in the functions of the blood coagulation system.

Age features. Children - most typically anterior bleeding. Elderly - most typically posterior bleeding.

Prevention. Lubrication of the nasal passages with petroleum jelly to prevent drying of nasal mucus and the formation of crusts, cutting nails.

Synonym. Epistaxis.

ICD-10. R04.0 Epistaxis.

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. №170

The publication of a new revision (ICD-11) is planned by WHO in 2017 2018.

With amendments and additions by WHO.

Processing and translation of changes © mkb-10.com

ICD code 10 nosebleeds; causes

At least once in a lifetime, everyone experiences such a nuisance as a nosebleed. It often happens that in young children, nosebleeds begin to flow "for no reason at all." However, there are still reasons for this phenomenon, and there are quite a few of them. If your child has frequent nosebleeds, then this cannot be ignored, you should definitely consult a doctor, as this may indicate the development of a serious and dangerous disease.

Nasal bleeding, ICD code 10

Nosebleeds in a child can be of two types:

Bleeding from the anterior parts of the nasopharynx (damaged vessel located in the nasal septum).
Bleeding from the back of the nose (it happens with trauma, high blood pressure, against the background of the appearance of some serious ailments).

In winter, a child's nose may bleed more often than in the warm season. Usually in children, blood comes from the front of the nose and only from one nostril. It's easy enough to stop her. If we are talking about damage to the vessel located in the back of the nose, then the blood comes from both nostrils at once and it is difficult to stop it. In any case, the task of parents is to stop the bleeding as soon as possible.

Nosebleeds, the ICD code 10 of which is R04.0, may appear for several reasons, we will consider them in more detail below.

Nosebleeds in children: what are the main causes

One of the main causes of this disease is damage to the vessels of the nasal mucosa, which occurs as a result of the following:

Nose injuries: external (bruise, fracture), internal (damage to a finger, nail, pencil, small object that got into the nose).
Inflammation of the nasal mucosa (sinusitis, adenoiditis, rhinitis).
Dryness of the nasal mucosa.
Operations in the nose area and various medical measures.
Polyps, tumors, tuberculous ulcers in the nose.
Thinning of the mucosa due to a violation of its nutrition (curvature of the nasal septum, atrophic rhinitis).
Increase in blood pressure.
High body temperature.
Deficiency of vitamin C, K, calcium
Sun or heat stroke.
Influenza and other infectious diseases.
Liver disease, hepatitis.
Sudden changes in atmospheric pressure and excessive physical exertion.
Hormonal changes in adolescence.
Dust, tobacco smoke, animal hair.
Too dry or hot air in the room where the child is constantly.
Strong stress.
Violation of blood circulation, blood clotting.
Trauma to internal organs.

If bleeding occurs frequently, consult a doctor who will prescribe the necessary tests and special studies to determine the presence or absence of diseases in the child.

Ignoring the problem of bleeding: what is dangerous

If bleeding occurs periodically, then they can cause exhaustion of the body and even the formation of anemia, in which immunity suffers (resistance to pathogens decreases, as well as to negative and constantly changing environmental conditions). With oxygen starvation, irreversible changes in the functions and structure of various human organs may appear.

The loss of a large amount of blood can lead to serious consequences and even death. In acute bleeding, a person’s well-being quickly deteriorates and he can lose consciousness, if the blood cannot be stopped, this can lead to death. It is very important to know how to act in order to quickly stop the bleeding in a child in order to avoid unpleasant consequences.

Help with nosebleeds: an algorithm

For a nosebleed in a child, proceed as follows:

Seat the child - the back should be straight, the body is only slightly tilted forward, the head is slightly lowered.
Squeeze the wings of the baby's nose with your fingers (that is, squeeze the nose).
Hold the child in this position for 10 minutes. Keep your nose pinched, don't peek to see if it's bleeding or not. Try to stay in this position for exactly 10 minutes.
It is desirable to apply cold to the bridge of the nose, for example, ice cubes. You can give the child something to eat or drink something cold (ice cream, cold juice through a straw).

Under no circumstances should you do the following:

Do not tilt the child's head back, as in this case, the blood will drain along the back wall of the nasopharynx, and the baby may choke with a large amount of blood.
Don't stuff cotton, tampons, or anything else up your child's nose as a "plug". The blood will dry up, and when you remove the swab, the bleeding will start again.
Do not let the child lie down, as with heavy bleeding and vomiting, the baby may choke.
Do not let the child talk or move, as this may increase bleeding.

When to Call a Doctor

Sometimes it is not possible to cope with the bleeding on your own, in which case you should immediately show the child to the doctor.

If after 10 minutes the nose is still bleeding, do the procedure again. If after 20 minutes the situation has not changed, then you need to urgently call an ambulance.
It is imperative to call emergency care if the bleeding is intense and immediately from two nostrils.
If the blood comes not only from the nose, but also from other organs.

With frequent bleeding (every 2-3 days, once a week, once a month), the child should also be shown to the local doctor, as this may be a symptom of a serious illness.

Askorutin for children with nosebleeds: dosage

Askorutin is a vitamin preparation containing vitamins C and P. This remedy is recommended for both children and adults, especially during seasonal outbreaks of infectious diseases and influenza. It is also great for prevention during the second and third trimesters of pregnancy.

The drug not only compensates for the lack of vitamins in the body, but also helps with frequent nosebleeds, which are caused by increased capillary fragility. Vitamins C and P, which are part of the drug, are well absorbed, improve the density and elasticity of blood vessels.

In addition, Askorutin is given to children in courses to reduce the incidence of colds. For preventive purposes, take 1 tablet in the morning, for colds - 2 tablets 3 times a day (duration of treatment - 3-4 weeks, the duration of the medication depends on the nature of the disease and the effectiveness of the treatment).

Askorutin is prescribed for children over 3 years old, it should be taken only after consulting a doctor, since the drug has certain limitations and contraindications, as well as allergic reactions and side effects. The price of this drug is available to all segments of the population.

Causes of nosebleeds in children

Nosebleeds in adults; causes and treatment

Add a comment Cancel reply

Use of materials only if there is an active link to the source

R04.0 Epistaxis

What is Nosebleed -

primary, due to local processes;
symptomatic associated with common causes (hereditary, congenital or acquired disorders of hemostasis and systemic diseases);
obvious and hidden (bleeding from the posterior parts of the nose, in which blood flows through the choanae along the back wall of the pharynx and is swallowed, less often aspirated).

What Causes Nosebleeds:

Frequent nosebleeds and increased bleeding of the mucous membrane in children are due to the peculiarities of the blood supply, the structure of the mucous membrane of the nasal cavity, and the superficial location of the vessels.

The most common site (80% of cases) of nosebleeds is a network of small blood vessels in the anteroinferior cartilaginous section of the nasal septum (Kisselbach's point), formed by the branches of the nasopalatine artery, its anastomoses and a powerful venous network of dilated vessels; all the arteries that supply this area with blood pass here into the venous network. Frequent bleeding in this area is due to cavernous tissue with poorly developed muscles, dense attachment, thinner and less extensible mucosa in this section.

Common causes of nosebleeds are due to diseases of the organs and systems of the body:

infectious diseases with hyperthermia and intoxication (influenza, measles, scarlet fever, diphtheria, typhoid, etc.);
diseases of the hematopoietic system (acute and chronic leukemia, hemorrhagic diathesis, immune hemopathy);
severe anemia and septic conditions;
decompensated conditions in diseases of the cardiovascular system, kidneys, liver and lungs:
hypo- and beriberi;
Randu-Osler disease with hemorrhagic angiomatosis and massive bleeding from easily injured multiple telangiectasias of the nasal mucosa due to congenital inferiority of the mesenchyme;
hypertension or sudden drop in blood pressure;
general overheating;
physical exertion, tense cough;
long exposure to the sun;
the use of anticoagulants, especially in renal failure against the background of severe impairment of peripheral circulation;
fracture of the base of the skull in the anterior region of the cranial fossa (accompanied by severe epistaxis and liquorrhea);
violation of the menstrual cycle in girls (vicarious nosebleeds);
the possibility of excretion through the nose of blood with bleeding from the esophagus, stomach and lower respiratory tract.

Among the local causes, various exogenous and endogenous factors are important:

nose injuries due to impact, fall;
surgical interventions;
bad habit of picking one's nose;
foreign bodies of the nasal cavity (at the time of introduction into the mucous membrane and as a result of their long stay with irritation of the mucous membrane and the growth of bleeding granulations);
tumors, especially vascular benign (hemangiomas, angiofibromas, bleeding polyp of the nasal septum) and malignant (cancer, sarcoma);
acute rhinitis;
chronic atrophic rhinitis;
deviated septum of the nose;
diphtheria and tuberculosis ulcers;
chemical, thermal, radiation and electrical burns of the nasal cavity.

Nosebleed symptoms:

Note hemorrhagic discharge from one or both halves of the nose, blood flow down the back of the throat.

Possible hematemesis or blood in the sputum when coughing against the background of general weakness, falling pulse and blood pressure, fainting with hidden bleeding.

The intensity of nosebleeds varies from minor to profuse, life-threatening child. Children do not tolerate blood loss. The loss of 50 ml of blood in a newborn in terms of consequences and influence on hemodynamics is equivalent to the loss of 1 liter of blood in an adult.

Nosebleed Diagnosis:

With nosebleeds, the diagnosis is made without much difficulty. Children are very sensitive to blood loss, so recurring even minor bleeding from the nose requires a thorough examination of the child and appropriate treatment.

Nosebleed Treatment:

With nosebleeds, emergency care is necessary, while the degree of blood loss is assessed by the general condition and 3 criteria: pulse, blood pressure and hematocrit.

Hemoglobin levels may be elevated due to thickening of the blood during massive bleeding.

Bleeding from the anterior septum of the nose stops relatively easily and simply.

After the introduction of a cotton swab into the nasal cavity, more often with hydrogen peroxide, the wing of the nose is pressed against the septum. Previously, the child must be given a sitting position to prevent a rush of blood to the head, hemorrhagic clots should be blown from the nasal cavity, and vasoconstrictor drops should be dripped. Cold lotions and ice are applied to the bridge of the nose and forehead.

With more persistent bleeding, a number of measures are taken: cauterize the bleeding area with chromic, trichloroacetic acid, 3-5% silver nitrate solution infiltrate the soft tissues of the nasal septum with 0.5% novocaine solution. Cryodestruction, ultrasonic disintegration and galvanoacoustics give a good effect. Cauterization or physical hemostatic effect on the bleeding section of the nasal septum on both sides is performed at different levels to prevent its perforation.

To stop bleeding, a hemostatic sponge, swabs with a 1% solution of feracryl, epsilon-aminocaproic acid, canned amnion, and dry thrombin are also introduced into the nasal cavity.

One of the effective methods is the detachment of the mucous membrane and perichondrium in the area of the bleeding area in order to empty the vessels and scar.

At the same time, general measures are taken, drugs that increase blood clotting are prescribed: calcium chloride and ascorbic acid are given orally, vikasol is administered intramuscularly, calcium chloride, calcium gluconate, hemophobin, epsilon-aminocaproic acid intravenously. In severe cases, transfusion of blood, platelet mass, gemodez, reopoliglyukin is performed. Liver extracts are used in the form of hepatocrine or campolone (2.0 ml 1 time intramuscularly). Spleen extract also increases blood clotting and increases platelet count.

A significantly greater danger to the health and even life of the patient is bleeding from the middle and posterior parts of the nasal cavity, from the branches of the ethmoidal and nasopalatine arteries and veins. In this situation, if the listed general and local methods of hemostasis fail, nasal tamponade (anterior or posterior) is performed.

Anterior nasal tamponade is performed when bleeding from the anterior parts of the nose. A sterile gauze swab impregnated with a hemostatic composition is laid in layers from bottom to top throughout the nasal cavity between the turbinates and the nasal septum. The swab is removed after soaking it with isotonic sodium chloride solution or 3% hydrogen peroxide solution to reduce trauma to the nasal mucosa and avoid rebleeding. A tampon left in the nose for a longer period can lead to the development of sinusitis or otitis media. If it is necessary to leave the tampon in the nasal cavity for a longer time, it must be soaked with an antibiotic solution or the anterior tamponade should be repeated with the introduction of a new sterile tampon.

With severe bleeding from the posterior parts of the nose and nasopharynx, a posterior nasal tamponade is performed. Prepare a gauze pad with three threads corresponding to the size of the nasopharynx, equal to approximately two nail phalanges of the child's thumb. A gauze swab is inserted into the nasopharynx through the oral cavity. Previously, a thin elastic catheter is passed into the nasopharynx along the lower nasal passage. When the end of the catheter enters the oral part of the pharynx, it is captured with a forceps or a Kocher clamp, removed through the mouth, and a nasopharyngeal swab is fixed to it with two thick silk threads. Then the catheter is brought back through the nose, with the help of the index finger, a tampon is passed over the soft palate and tightly fixed in the choana.

The end of the thread coming out of the mouth is fixed with a sticky patch to the cheek.

The posterior tamponade of the nose is combined with the anterior one, a gauze roller is strengthened over the tampons, over which two threads are tied so that the nasopharyngeal tampon descends downward into the oropharynx. The tampon should not be left in the nasopharynx because of the risk of infection spreading through the auditory tube into the middle ear with the development of otitis, as well as through the cribriform plate into the anterior cranial fossa. The tampon is removed from the nasopharynx with the help of the end of the thread that goes into the oral cavity after the removal of the anterior tampon.

It should be borne in mind that spontaneous nosebleeds in patients with hypertension are hypercoagulable, caused by consumption coagulopathy due to an increase in anticoagulant activity of the blood and lysis of loose clots, a decrease in vascular resistance, impaired platelet function, and the formation of heparin complex compounds. In this regard, when stopping their nosebleeds, hypocoagulation agents are used in complex therapy under the control of a thrombo-elastogram (indirect anticoagulants - dicoumarin, nitrofarsin, phenyl in).

With repeated persistent bleeding from the ethmoid arteries, coagulation of the branches of the ethmoid artery from the side of the orbit after detachment of the periosteum of its medial wall is also used to stop them.

With the failure of general and local hemostatic measures with intense, life-threatening bleeding, the external carotid arteries are ligated.

Nosebleeds: Symptoms and Causes

Nosebleeds - Causes

Local provoking factors include:

Injury - injuries of the nasal mucosa, provoked by the ingress of a foreign object, injuries after surgery
diseases that provoke a glut of blood secretions of the nasal mucosa - acute and chronic rhinitis, sinusitis, adenoids
neoplasms - cancer, angioma in the deepening of the nose
deviations of a dystrophic nature in the nasal mucosa - deviations of the nasal septum from the midline

Common reasons include:

cardiovascular diseases - heart disease, atherosclerosis
elevated body temperature due to the presence of an acute infectious disease, as a result of overheating or sunstroke
the presence of pathologies that cause barometric pressure (its drops) - a syndrome that occurs in the practice of pilots, climbers or divers
hormonal imbalance (hemorrhage during pregnancy, puberty)
blood clotting changes
menstrual disorders (vicarious nosebleed)

Symptoms

The main signs of nosebleeds will help establish the diagnosis - the discharge of blood from the nostrils outward or through the nasopharynx into the oral cavity. If the hemorrhage occurred at night, during sleep, you can swallow the secretions of blood. Therefore, in vomit or feces, blood discharge can be detected. If the syndrome is caused by the presence of a disease, the patient is diagnosed with the symptoms of the disease that provoked the disease.

If the patient has profuse nosebleeds, symptoms of anemia (headache, weakness, pale skin) may occur. The severity of symptoms depends on the type of bleeding, the volume of blood loss, the age and gender of the patient.

A person may experience the following symptoms:

complaints of general malaise
noise or ringing in the ears
headache and dizziness
pale skin
heart beats faster
thirst

Diagnostics

If the doctor suspects that the patient has diseases of the blood or the cardiovascular system, the patient is prescribed a blood test from a finger, a coagulogram, and blood pressure is measured.

Types of bleeding

Epistaxis, depending on the place of occurrence, can be:

Anterior nosebleeds are usually characterized by low intensity and are not dangerous to human health. Anterior nosebleeds can stop without outside intervention (if a person does not have blood and vascular diseases) or using the simplest first aid measures.

Degrees of blood loss

Depending on how much blood has flowed out of the nasal cavity, several degrees are distinguished:

Minor stage - stands out from a couple of drops to a couple of milliliters of blood secretions. It does not threaten the health and life of a person, the patient does not feel pain or discomfort. Symptoms are mild. The only negative consequence may be fright or fainting in children.
Mild degree - a person loses no more than 700 ml of blood. A person may experience the following symptoms - dizziness, pallor of the skin, increased heart rate.
The average degree - a person loses blood from 1000 to 1400 ml. Symptoms are more pronounced - headache, tinnitus, general malaise, thirst.
Severe stage - it is characterized by severe nosebleeds. The amount of leaked blood is more than 20% of all blood moving through the vessels. Massive bleeding syndrome causes hemorrhagic shock. Frequent nosebleeds increase the risk of anemia.

When help is needed

In what cases is medical assistance required:

great loss of blood
hemorrhage provoked by trauma to the nasal cavity
fever and headache
hemorrhage does not stop for a long time

Blowing your nose is strictly prohibited, as this process does not allow the damaged vessel to clog with blood clots and eliminate hemorrhage. Cold is applied to the bridge of the nose (a container with ice). This will help narrow the vessels and stop epistaxis.

Preventive measures are aimed at:

strengthening the walls of blood vessels
providing indoor air humidity
daily diet should include minerals and vitamins
prevention of injury to the nasal cavity

Join and get useful information about health and medicine

Nose bleed

Definition and background[edit]

Nosebleeds (epistaxis) occur at least once in a lifetime in every fifth person. It most often occurs in middle-aged men.

Etiology and pathogenesis[edit]

The most common causes of nosebleeds are trauma, surgery (surgical interventions on the paranasal sinuses, conchotomy, rhinoplasty, nasal septum plasty) and arterial hypertension. Other reasons are too dry air in a heated room (leads to the formation of crusts and ulceration of the mucous membrane), a difference in atmospheric pressure (for example, in an airplane).

Nosebleeds are usually short-lived and easy to stop. Severe bleeding that cannot be treated with simple methods is less common. They can lead to massive blood loss, arterial hypotension, and cardiovascular disorders.

Clinical manifestations[edit]

Nosebleeds: Diagnosis[edit]

Differential diagnosis[edit]

Nosebleeds: Treatment[edit]

Severe bleeding may occur during treatment with anticoagulants (heparin or warfarin); sometimes it is necessary to interrupt therapy. Some analgesics and antipyretics interfere with platelet function. Aspirin and preparations containing aspirin (Alka-Seltzer, Perkodan, Talvin, etc.) inhibit platelet aggregation and can provoke bleeding.

Blood diseases (leukemia, anemia, hemophilia, erythremia, lymphoma), liver disease, chronic renal failure, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) may be accompanied by severe nosebleeds. A family history is taken to detect coagulopathy; determine bleeding time, APTT and PV; count the number and examine the function of platelets. With coagulopathy, to stop nosebleeds, treatment is required to normalize blood clotting.

Inflammatory diseases, foreign bodies, and neoplasms are rarer causes of nosebleeds. Recurrent bleeding from one side of the nose, combined with difficulty in nasal breathing, pain and swelling of the face, suggests a swelling of the nose or paranasal sinus. Conduct an examination of the nasal cavity and, if possible, CT. For rhinoscopy, a fiberscope is used.

Bleeding can occur in the anterior (80-90% of cases) or posterior parts of the nasal cavity. In order to identify a bleeding area, good lighting (head light or forehead reflector), vision (nasal mirror) and suction (Frasier tip) are necessary. The headlight allows the clinician to manipulate the nasal speculum and suction at the same time. For anesthesia, narrowing of blood vessels and drying of the mucous membrane, a cotton swab moistened with 4% cocaine or a mixture of 2% tetracaine with adrenaline at a dilution of 1: 100,000 is inserted into the nasal cavity. The swab is left in the nasal cavity for at least 10 minutes. You can also use 1% phenylephrine (nasal spray or swab). Sometimes this is enough to stop the bleeding.

If the patient has recently undergone surgery (septoplasty, rhinoplasty, etc.), nasal tamponade can nullify its results. In this case, you must immediately notify the surgeon who operated on the patient. If bleeding occurs after septal plastic surgery, he will most likely have to remove the hematoma that has formed between the mucoperchondral flaps. With massive blood loss, nasal tamponade is necessary.

Prevention[edit]

Other [edit]

Bleeding from the anterior nasal cavity

A. When bleeding from the anterior parts of the nasal cavity, the blood usually flows from one nostril. In 90% of cases, the source of bleeding is the choroid plexus of the anteroinferior part of the nasal septum (Kisselbach zone). Bleeding can be venous or arterial. With arterial bleeding, which is much less common than venous bleeding, a pulsating damaged artery is visible.

B. In many cases, to stop bleeding, it is enough to spray a vasoconstrictor drug (phenylephrine, oxymetazoline, etc.) into the nasal cavity. These funds are especially useful for nosebleeds that occur after surgical interventions (rhinoplasty, nasal septum plasty).

C. After treatment with a vasoconstrictor and a local anesthetic, the bleeding area can be localized and cauterized. Cauterization is carried out with a probe, on the head of which silver nitrate is soldered. Carefully treat the bleeding area (2-4 mm in diameter), trying not to touch the surrounding tissues and the bottom of the nasal cavity. Preliminary constriction of the vessels of the mucosa reduces the discharge from the nose and prevents the spreading of the caustic agent. Bipolar diathermocoagulation minimizes damage to surrounding tissues. Particular care is taken not to damage the edge of the nostril. Laser coagulation (CO2 laser, liquid dye laser with tunable wavelength) can be used, but this method requires special skills.

D. If cauterization is impossible or it has no effect, resort to anterior tamponade of the nose with gauze turunda. Turunda is impregnated with an antibiotic ointment. You can use hemostatic plates (eg, Surgicel) impregnated with bacitracin ointment. The plate is applied to the bleeding area and a gauze turunda is laid in layers on top of it. The pressure on the bleeding area should be strong enough. For the prevention of sinusitis, antibiotics are prescribed (ampicillin, 250 mg 4 times a day orally). The swab is removed after 1-3 days. In case of repeated bleeding, the bleeding area is cauterized and tamponade is performed again.

Bleeding from the back of the nose

A. When bleeding from the posterior parts of the nasal cavity, the blood drains into the pharynx through the choana and can simultaneously flow out of the nostril. With profuse bleeding, blood can flow from both nostrils, swallowing blood, followed by hematemesis, blood entering the respiratory tract and hemoptysis.

B. If, after anterior tamponade, blood continues to flow into the pharynx, the source of bleeding is in the posterior sections. Most often, these are the sphenopalatine vessels (posterior part of the septum), Woodruff's venous plexus (lateral wall of the nasal cavity at the border of the lower nasal and nasopharyngeal passages) and ethmoid vessels (posterior superior part of the septum). After operations on the nasal septum, bleeding from a dissected bone or septum is possible. After endoscopic operations on the paranasal sinuses, the injured nasal mucosa may bleed.

B. The main method of stopping bleeding from the posterior parts of the nose is posterior tamponade. The posterior tampon closes the choana and prevents the gauze turunda from moving from the anterior parts of the nose into the pharynx. Before tamponade, you need to make sure that the airway is patent. Posterior tamponade should be carried out by a physician skilled in the technique of intubation, since airway obstruction may occur at any time.

D. Classical method of posterior tamponade (see Fig. 25.15). A gauze swab is tied crosswise with two threads; one end is cut off, three are left. Treat the nasal mucosa and posterior pharyngeal wall with local anesthetics; sedatives are administered (if hemodynamics and respiration are stable). A catheter is inserted through the nose into the oropharynx. The end of the catheter is brought out through the oral cavity and a tampon is tied to it with two threads. Then the catheter is pulled in the opposite direction, and the tampon is inserted with a finger into the nasopharynx behind the soft palate and pressed against the choana. Then an anterior tamponade of the nose is carried out with gauze turunda soaked in an antibiotic ointment. The back tampon plays the role of a damper that prevents the turunda from entering the nasopharynx. Two threads brought out through the nose are tied at the entrance to the nose above the gauze roller. The third thread left in the mouth is intended to remove the tampon, it is fixed with adhesive tape on the cheek. The classical method of posterior nasal packing is a complex procedure; it should be carried out by a doctor who is well acquainted with the topographic anatomy of the head and neck.

E. A simpler method of posterior tamponade is based on the use of a Foley catheter. A 14 or 16 F catheter with a 30 ml balloon is inserted into the nasopharynx, filled with 10-15 ml of saline and pulled back until it stops (until the balloon reaches the choana). If necessary, completely close the lumen of the choana, a saline solution is added to the can. Then an anterior nasal tamponade is carried out with gauze turunda soaked in an antibiotic ointment. The inflated balloon prevents the turunda from entering the nasopharynx. The Foley catheter should not press on the edge of the nostril, so as not to cause necrosis of it.

E. Epistat intranasal contour balloons are often used in emergency rooms and emergency rooms. The device consists of two balloons - the rear one, which plays the role of a damper, and the front one, which puts pressure on the source of bleeding. This method is quite simple, but not as effective as the classic posterior tamponade. If the balloon is inflated too much and left for a long time, it compresses the nasal septum and can lead to necrosis.

G. After the posterior tamponade of the nose, the patient is hospitalized. Prescribe sedatives, antibiotics, oxygen inhalation. With complete obstruction of the nasal passages, breathing is carried out only through the mouth, so hypoventilation and a decrease in pO 2 are possible. Carefully monitor the patient: possible hypoxia, toxic shock, resumption of bleeding. Epistat contour balloons allow you to breathe through the nose due to the presence of a central channel, so after stopping the bleeding, the patient can be allowed to go home under the supervision of the attending physician.

3. With repeated or persistent nosebleeds, when nasal tamponade is ineffective, ligation of a large vessel is indicated. In case of bleeding from the posterior inferior sections of the nasal cavity, the branches of the maxillary artery are tied up (approach through the posterior wall of the maxillary sinus). Another way is to ligate the external carotid artery above the origin of the superior thyroid artery; it is less effective due to well-developed collateral circulation. With incessant bleeding, the source of which is located above the middle nasal concha, an arcuate incision is made in the medial wall of the orbit and the anterior and posterior ethmoid arteries are ligated (external ethmoidectomy). The vessels pass in the upper part of the medial wall of the orbit in the suture between the orbital plate of the ethmoid bone and the frontal bone.

I. In case of persistent epistaxis, if the ligation of the vessel was ineffective, angiography and embolization of the maxillary artery is indicated. With the help of angiography, it is possible to establish the cause of the ineffectiveness of the dressing: the presence of collateral circulation or anastomoses between the maxillary and ethmoid arteries. Embolization can be performed repeatedly.

Sources (links)[edit]

1. Kirchner, J. A. Current concepts in otolaryngology: Epistaxis. N. Engl. J. Med. 307:1126, 1982.

2. Milczuk, H. A., et al. Quest for the aberrant vessel. Otolaryngol. Head Neck Surg. 104:489, 1991.

3. Pearson, B. W. Epistaxis: Some observations on conservative management. J. Laryngol. Otol. 8(Suppl.):115, 1983.

4. Randall, D. A., and Freeman, S. B. Management of anterior and posterior epistaxis. Am. fam. Physician 43:2007, 1991.

5. Shaw, C. B., Wax, M. K., Wetmore, S. J. Epistaxis: A comparison of treatment. Otolaryngol. Head Neck Surg. 109:60, 1993.

6. Wurman, L. H., et al. The management of epistaxis. Am. J. Otolaryngol. 13:193, 1992.