Bleeding nose

Bleeding nasal is a common pathological condition that complicates the course of many diseases. The range of its possible manifestations and consequences is very large. In most cases, patients with minor hemorrhage of nosebleeds do not seek medical help, using simple self-help methods for stopping it.

The provision of medical care for this pathology, stopping bleeding refers to general medical manipulation. However, intensive bleeding, a recurrent bleeding pattern, requires specialized medical care. Patients with nasal bleeding in the structure of patients hospitalized in otorhinolaryngological departments make up to 10%.

Etiology

Blood supply to the mucous membrane of the nasal cavity is carried out by arteries from the basins of the outer and inner carotid arteries, the main vessels are the basic palatine (a. sphenopalatinum) from the external carotid system, the anterior and posterior arteries (branches of the eye artery from the basin Internal carotid).

The main-palatine artery through the hole of the same name penetrates into the nasal cavity and branches into the posterior nasal lateral and septal arteries (aa. Nasales posteriores laterals et septi), blood supplying the posterior sections of the nasal cavity. The front ethmoid arteries pass into the nasal cavity through the trellis plate, the posterior ones through the posterior trellis opening, they provide blood supply to the area of ​​the latticed maze and the anterior part of the nasal cavity. The outflow of blood is carried out into the anterior facial and orbital veins.

The direct cause of nasal bleeding is a violation of the integrity of the vessels of the mucous membrane of the nasal cavity. Possible causes of nasal bleeding are divided into local and general.

Local processes leading to epistaxis include:

• All types of nasal and intra-nasal injuries (including mucosal trauma due to foreign matter, operating injuries, trauma in treatment and diagnostic manipulations in the nasal cavity - puncture and catheterization of the paranasal sinuses, nasotracheal intubation, nasogastric probing, endoscopy, etc.);

• Processes that cause the fullness of the mucous membrane of the nasal cavity (acute and chronic rhinitis, sinusitis, adenoid vegetation);

• Dystrophic changes in the mucous membrane of the nasal cavity (atrophic forms of rhinitis, pronounced curvature of the nasal septum);

• Neoplasms of the nasal cavity (angiomas, malignant tumors, specific granulomas).

Sufficiently diverse are possible causes of a general nature that can lead to nasal bleeding:

• Diseases of the cardiovascular system (hypertension and symptomatic hypertension, heart defects and vascular abnormalities with increased blood pressure in the vessels of the head and neck, arteriosclerosis of the blood vessels);

• Coagulopathy, hemorrhagic diathesis and diseases of the blood system, hypo- and avitaminosis;

• Hyperthermia as a result of acute infectious diseases, heat and sun shock, with overheating;

• Pathology as a result of sharp changes in barometric pressure (pathological syndromes in flight, diving, climbing practice);

• Some hormonal imbalances (juvenile and vicarious bleeding, bleeding during pregnancy).

The clinical picture of nasal bleeding includes:

• Direct signs of bleeding;

• Symptoms of causative pathology;

• Signs of acute hemorrhage.

A direct sign of nasal bleeding is the visually determined flow of blood from the lumen of the nostrils to the outside and / or the inflow of blood from the nasopharynx into the oropharynx, which is detected with pharyngoscopy.

Symptoms of causal pathology are diverse and reflect the severity, stage and form of the disease or injury.

The emerging signs of acute blood loss depend on the characteristics of bleeding (localization, intensity), the volume of lost blood, premorbid status, age and sex of the patient.

Nasal bleeding by localization can be "front" and "posterior".

In the anterior part of the nasal septum, the Kisselbach zone (bleeding nasal zone) is located on both sides, which causes bleeding in 90-95% of cases. The frequency of damage to this area is caused by a large number of capillaries anastomosing with each other, originating from the basins of the septa, a large palatina major, anterior etaloidal anterior and anterior labialis superior, Arteries. The mucous membrane of this region is thin, practically devoid of the submucosa, which makes the vessels located here vulnerable to both external mechanical action and increased local intravascular pressure.

"Anterior" bleeding, not intense in nature, rarely poses a threat to life and can stop on its own (in the absence of coagulopathy) or when using the simplest first aid measures.

In contrast to the "front", with "posterior" nasal bleeding (damage to sufficiently large vascular trunks, which are mainly localized in the walls of the deep sections of the nasal cavity), the volume of blood loss rapidly increases, which is a threat to life. Self-similar bleeding stops very rarely and require special stop methods.

Depending on the volume, the degree of hemorrhage in nasal bleeding is divided into minor, mild, moderate, severe or massive.

A small amount of blood loss is from a few drops to several tens of milliliters. Such bleeding does not lead to the development of any metabolic changes in the body and in most cases does not give pathological symptoms. However, in childhood and in persons with a labile psyche, it can be accompanied by reactions of psychogenic (hysterical) or vegetative-vascular (fainting) nature.

With mild degree of blood loss is up to 10-12% of the volume of circulating blood (500-700 ml in an adult). The patients complain of weakness, noise, ringing in the ears, flashing of flies before the eyes, thirst, dizziness, palpitations. There may be a slight pallor of the skin and visible mucous membranes.

With the increase of blood loss to 15-20% of the volume of circulating blood (1000-1400 ml for an adult), an average severity is diagnosed. Subjective symptoms increase, tachycardia, lowering of arterial pressure, dyspnea and signs of peripheral vasospasm (acrocyanosis).

The blood loss of more than 20% of the circulating blood volume leads to hemorrhagic shock development (inhibition and other disorders of consciousness, pronounced tachycardia, threadlike pulse, a sharp drop in blood pressure, etc.).

Diagnostics

The diagnosis of the fact and type ("front" or "back") of nosebleeds is not particularly difficult and is established on the basis of external examination, anterior rhinoscopy and pharyngoscopy. In some cases, it is necessary to differentiate the nosebleeds from so-called bleeding from the nasal cavity, in which the nasopharynx, airways and lungs, the esophagus pathways and the stomach can be the source of bleeding. In these cases, blood flow into the nasal cavity through the choanae is possible, followed by outflow from the lumen of the nostrils.

With pulmonary hemorrhages, the blood is bright red, frothy. Bleeding is accompanied by a cough. In cases of gastric bleeding, the blood is dark in the form of coffee grounds. However, such a character of blood during vomiting can also be observed with nosebleeds due to swallowing of blood draining into the pharynx.

A more complex diagnostic task is to determine the cause (etiology) of nasal bleeding and estimate the amount of blood loss. Use the generally accepted methods of clinical and paraclinical examination (general blood test, coagulogram, etc.).

Treatment

Principles of medical care for nosebleeds include:

• The fastest stop of bleeding to prevent the increase of blood loss;

• Etiotropic therapy (for example, hypotensive therapy for hypertensive disease);

• Struggle against consequences or prevention of possible consequences of acute blood loss (hypovolemia, hemorrhagic shock, thrombohemorrhagic syndrome, posthemorrhagic anemia);

• Hemostatic therapy.

Methods of stopping nasal bleeding

1. The simplest methods of stopping bleeding.

With an "terior "nosebleed to stop it enough:

- give the patient a sitting position or horizontal with an elevated head end (the head does not tilt, as otherwise there is difficulty in venous outflow from the vascular network of the head and neck, which increases regional blood pressure and increases bleeding, in addition, conditions for ingesting blood are created) ;

- In the bleeding half of the nose, insert a cotton or gauze ball, moistened with vasoconstrictive solution (if the cause of bleeding is not increased blood pressure), 3% solution of hydrogen peroxide, or some other hemostatic drug;

- Press the wing of the nose with your finger outside to the nasal septum and hold it for 10-15 minutes (if the patient is able to do it himself);

- impose a "cold" on the nose bridge area (wet towel, rubber bubble with ice, etc.);

- calm the victim, especially if it is a child.

2. Anterior tamponade of the nasal cavity.

Indications for anterior tamponade of the nasal cavity are:

- Suspicion of "back" bleeding;

- ineffectiveness of the simplest methods of stopping the "front" nosebleed within 15 minutes.

For the front tamponade of the nose as a tampon use long (50-60 cm), narrow (1.5-2.0 cm) turundas made from bandage. Such a tampon should be moistened with a hemostatic paste or vaseline oil and, using the nasal mirror and cranked tweezers, tightly, in the form of vertical knees, consistently fill the corresponding half of the nose, beginning with the deep sections. On average, for a tight front tamponade, one half of the nose in adults requires 2-3 similar tampons (approximately 1.0-1.5 meters). If necessary, produce a tamponade of both halves of the nose.

After carrying out the front tamponade of the nasal cavity, it is necessary to evaluate its consistency. A sign of effectiveness is the absence of bleeding not only outward (from the lumen of the nostril), but also along the back wall of the pharynx (check for pharyngoscopy).

After the introduction of tampons on the nose, impose a sling dressing.

Correctly executed anterior tamponade of the nasal cavity reliably stops bleeding from the anterior parts of the nasal cavity and in most cases with the "posterior" localization of the source of bleeding. The mechanism of anterior tamponade is due to mechanical pressure on the affected area of ​​the mucous membrane, the pharmacological action of the drug, which moistened the tampon. In addition, the anterior tamponade serves as a framework that holds the blood clot at the site of vascular injury.

3. Rear tamponade of the nasal cavity.

With the continuation of bleeding after the front tamponade (the blood flows down the back of the throat), one should resort to the posterior tamponade of the nasal cavity. To this end, 1-2 dense gauze tampons are required in triangular form with three firmly secured (stitched) silk ligatures from opposite sides (single on "stupid" and double on "sharp" end), tampons for anterior tamponade, thin rubber catheter, tweezers, A nasal mirror, a spatula, a sling-like dressing.

The posterior tamponade begins with a catheter through the bleeding half of the nose into the nasopharynx and the oropharynx, where its end is grasped with forceps and extracted through the mouth (the second end of the catheter should not go into the nasal cavity). Both ligatures of the "acute" end of the tampon are attached to the oral end of the catheter and extracted by a catheter outward. The ligature threads are tightened, seeking the introduction of a rear swab into the nasopharynx and tight fixation of the "sharp" end in the lumen of the choana. Holding the tampon in this position, perform an anterior tamponade of the nose and fix the ligatures with a knot on the gauze ball in the area of ​​the nasal vestibule. The ligature of the "dull" end of the tampon remains in the pharyngeal cavity and serves for the subsequent extraction of the tampon. They impose a sling-like bandage.

Removal of gauze tampons is done very carefully, thoroughly impregnated with a solution of 3% hydrogen peroxide, on the 2nd day with a front tamponade and on the 7-9th at the back.

Instead of gauze tampons, you can use latex hydraulic or pneumatic tampons for the nasal cavity.

4. Surgical methods of stopping nasal bleeding.

With ineffectiveness of the posterior tamponade of the nasal cavity (the resumption of bleeding after its removal), it is possible to use surgical (ethmoidotomy followed by a tight tamponade of the postoperative cavity, ligation of the external or common carotid artery) or endovascular methods (embolization of the branches of the maxillary artery).

With recurrent bleeding from the anterior part of the nasal septum, the cause is often the erosively altered mucosa. In such cases it is necessary to apply methods of stimulating the epithelialization of the damaged surface (application of hemostatic sponges, auto fibrin film, vitamin-ointment ointments, etc.).

If the cause of recurrences of "anterior" bleeding is the expressed vasoconstriction of vessels in the Kisselbach zone, it is possible to use techniques that lead to the obliteration of the capillary bed (chemical sclerosing preparations, mucosal detachment, cryodestruction, electrocoagulation).

In cases of severe nasal bleeding, the casualties are most often caused by the ambulance brigade, whose personnel should conduct an anterior tamponade of the nasal cavity, if necessary, administer antihypertensive drugs and carry out the simplest substitution and hemostatic measures. The patient is taken to the inpatient department of the hospital.

At the hospital stage, the otolaryngologist conducts a stop of nasal bleeding by one or another method, the cause of bleeding is established, the volume of blood loss is estimated.

In case of massive blood loss, the treatment is performed by a complex otolaryngologist, therapist, cardiologist, hematologist, transfusiologist and resuscitator if necessary, since in this case only timely and complex therapy can lead to a favorable outcome.