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Epistaxis is one of the most common types of bleeding that a doctor of any specialty can meet.
In military otorhinolaryngology, nosebleeds caused by trauma caused by a blunt or sharp object, or firearms are of the greatest importance. It is important to note, however, that in most cases nosebleeds are a symptom of some general illness. So, according to Yu. V. Mitin et al. (1995), in 83% of cases, epistaxis is a consequence of general disorders, and only in 15% it is caused by local disturbances in the nasal cavity and paranasal sinuses.
The causes of nosebleeds are usually divided into local and general. Among the local causes should be mentioned: 1) injuries of the nose and paranasal sinuses; 2) atrophic processes of the mucous membrane of the anterior nasal septum, accompanied by the formation of crusts, the removal of which violates the vascular wall, 3) malignant tumors of the nose and paranasal sinuses; 4) benign tumors (angiomas, angiofibromas); 5) foreign bodies of the nasal cavity.
The common causes of nosebleeds are especially numerous. The most common of them include the following: 1) arterial hypertension and atherosclerosis; 2) acute infectious lesions of the upper respiratory tract mainly of viral origin; 3) septic conditions (chroniosepsis), intoxication, including alcoholic; 4) diseases of internal organs (cirrhosis of the liver, chronic glomerulonephritis, heart defects, emphysema, pneumosclerosis); 5) neurovegetative and endocrine vasopathies observed in girls during puberty, in girls and women with dysfunction of the ovaries, with toxicosis of the second half of pregnancy, vicarious (replacing) nosebleeds with delayed menstruation; 6) hypo- and vitamin deficiency; 7) lowering atmospheric pressure, physical overvoltage and overheating.
Particular attention should be paid to diseases of the vascular wall and violations of the coagulation properties of blood. Among them: thrombocytopenic purpura, hemorrhagic capillaropathy (angiohemophilia, von Willebrand disease), hemorrhagic angiopathosis (Randu-Osler disease), hemorrhagic vasculitis (Shenlein-Genoch disease), leukemia, polycythemia, pernicious leukemia anemia.
Mention should also be made of a condition often encountered in clinical practice, known as fibrinolysis. It can develop in people with normal blood coagulation as a result of spontaneous imbalance in its coagulation properties. At the same time, the activity of the fibrinolytic system increases, caused by trauma or surgical intervention. A large amount of fibrinolysis activator, plasmin (fibrinolysin), is released into the blood. The activation of fibrinolysis, observed under various stressful conditions, indicates that fibrinolysis is one of the protective reactions of the body, however, in this case, plays an inadequate role. Of practical interest are the reports of A.I. Vlasyuk (1969) and Rasmussen (1966) about the possibility of developing local fibrinolysis during spontaneous nosebleeds, while the fibrinolytic activity of blood obtained from the ulnar vein remains within normal limits.
Most often (in 80-90% of cases), nosebleeds occur in the anterior-lower part of the nasal septum (locus Kiesselbahii), which is associated with the peculiarity of the blood supply to this area. It is in this place that the final branches of the arteries supplying the nasal septum end. The arterial and venous network forms here several layers of the vascular plexus, which is easily injured.
The most severe bleeding is observed from the posterior-lower parts of the nasal cavity (pool of the external carotid artery). Bleeding from this area is more often noted in patients with hypertension and atherosclerosis (A. Likhachev, 1963). In case of nasal injuries, bleeding usually occurs from the upper divisions supplied from the anterior ethmoid artery (basin of the internal carotid artery).
Clinic and diagnosis. The diagnosis of nosebleeds is not difficult, but finding a bleeding site is not always easy. If bleeding occurs from the antero-lower sections of the nasal septum (locus Kiesselbahii), then it can be easily detected with anterior rhinoscopy. With bleeding from the deep sections of the nasal cavity, the source of hemorrhage in most cases cannot be established.
Epistaxis may occur suddenly. Sometimes it is preceded by prodromal phenomena (headache, tinnitus, dizziness, general weakness). Usually one side bleeds. The intensity of bleeding is different from a small “drop by drop” (in Greek - epistaxis), which gave a common name to all nosebleeds, up to massive, profuse. The most severe, life-threatening are the so-called signaling nosebleeds, they are characterized by suddenness, short duration and an abundance of poured blood. After spontaneous cessation of bleeding, severe collapse develops. Signal nosebleeds are a sign of a violation of the integrity of a large arterial vessel in the nasal cavity, bones of the facial skeleton, the base of the skull with severe trauma, exfoliating aneurysm, a decaying malignant tumor. Such nosebleeds are an indication for urgent hospitalization of a patient in a hospital and for taking measures to prevent the consequences of severe blood loss, prevent possible relapse and identify its source (G. Grigoriev, S. Piskunov et al., 1991).
In some cases, there is a problem of differential diagnosis between nosebleeds and bleeding from the lower respiratory tract, as well as from the esophagus and stomach. Blood with pulmonary hemorrhage is foamy, bleeding is accompanied by a cough, with gastric bleeding - dark, clotted. It should be borne in mind that swallowed blood with nosebleeds is accompanied by vomiting with clots of dark, brown clotted blood mixed with gastric contents, as with gastric bleeding. However, runoff on the back wall of red blood confirms nosebleeds.
Treatment. Regardless of the cause of nosebleeds, it should first be stopped. For this, there are a number of techniques, the sequence and volume of which depends on the intensity, duration of bleeding and the success of the measures taken.
Stopping bleeding is a responsible procedure. With its proper implementation, further blood loss is prevented, and the patient gets rid of repeated unpleasant manipulations.
In case of bleeding from the anterior part of the nasal septum - you should try to stop it by pressing the bleeding half of the nose wing with your fingers to the nasal septum. On the eve of the nose, you can additionally introduce an adequate cotton ball - dry or moistened with 3% hydrogen peroxide solution. It is important to note that the patient should not throw his head back, because at the same time, jugular veins are squeezed on the neck, and bleeding can intensify. With continued hemorrhage, especially in cases where the site of bleeding is visible, it is recommended, after local anesthesia, to cauterize the bleeding vessel with an electrocautery, carbon dioxide or YAG-iodium laser.
In order to cauterize a bleeding vessel of the nasal septum, the so-called lapis "pearl" made as follows. The crystal of lapis (silver nitrate), stored in a darkened glass jar with a ground stopper, is touched with the end of a button probe heated on an alcohol lamp. The lapis is fused to the probe in the form of a "pearl", which extinguish a bleeding vessel under the control of vision. However, this method, especially with its repeated repetition, is fraught with the development of atrophic processes in the anterior part of the nasal septum.
If the listed measures remain unsuccessful, resort to anterior tamponade, and in case of insufficiency, to the posterior tamponade of the nose. The most famous methods are Mikulich, Voyachek and Likhachev. All types of nasal tamponade, with nosebleeds, are produced after preliminary anesthesia of the mucous membrane of 5-10% r-rum cocaine or 2% r-rum dicaine. However, during ongoing bleeding, satisfactory anesthesia is not always possible. Tamponade, depending on the condition of the patient, is performed in a sitting or lying position.
Front tamponade of the nose according to Mikulich.
It is carried out most quickly and simply. The corresponding nostril is dilated by the nasal mirror. Using a forceps, a tampon prepared from a gauze bandage with a width of 1-2 cm and a length of up to 70 cm, and impregnated with liquid paraffin, to a depth of 6-7 cm, is inserted into the nasal cavity with a forceps. It is necessary, as with all types of anterior tamponade, to follow so that the tampon insertion tool is directed towards the choan along the bottom of the nose, and not toward its arch. The patient's head should not be thrown back. Gradually, the entire swab fits into the nasal cavity in the form of an "accordion" (Fig. 2.5.1) from the bottom up, until it densely fills the corresponding half of the nose. The excess swab is cut off, and the remaining end is wound on a fleece ("anchor").
The deficiency of the anterior nasal tamponade according to Mikulich is that the inner end of the tampon can shift through the choana into the throat and cause the urge to vomit, which often causes the bleeding to resume. This drawback is eliminated when conducting anterior nasal tamponade according to Voyachek and Likhachev.
Anterior tamponade of the nose according to Likhachev.
More technically simpler is tamponade of the nose according to Likhachev. Its difference from tamponade according to Mikulich is that a thread is attached to the end of the gauze swab inserted into the nasal cavity, with the help of which this end is tucked anteriorly and does not fall into the nasopharynx (Fig. 2.5.2).
Anterior looped tamponade of the nose according to Voyachek.
Its distinctive feature from those described above is the preliminary introduction to the entire depth of the nasal cavity of a wider gauze swab (2 cm wide), doubled in a loop (Fig. 2.5.3). A loop formed like a bag is filled with shorter and narrower insertion tampons (1-1.5 cm wide). The protruding ends of the loop swab should be firmly fixed to the outside of the nostrils using a cotton or gauze "anchor".
When removing the loop swab - first remove the internal swabs, and then the loop swab.
Rear nasal swab.
Proposed by Bellock. As already mentioned, they resort to it in those cases when all other methods of stopping nosebleeds have been exhausted. The posterior cotton-gauze swab for the nasopharynx is prepared and sterilized in advance. In exceptional cases, it is prepared ex tempore from a sterile material. The optimal size of the swab should correspond to the terminal phalanges of the thumbs folded together (Fig. 2.5.4). The tampon is bandaged crosswise with two thick strong threads. Of the four ends formed, one can be cut off (optional).
After local anesthesia, a rubber catheter is inserted through the bleeding half of the nose into the oropharynx, the end of which is removed through the mouth with a forceps. Both threads are tied to the withdrawn end of the catheter. When the catheter is brought back through the nose, thanks to the strands tied to it, the tampon is inserted into the nasopharynx, tightly pulling up to the choanas (Fig. 2.5.5). Holding the threads in a tight state, produce anterior nasal tamponade. The tamponade ends with tying the threads over a cotton or gauze “anchor” necessarily a “bow”, which allows you to pull up the shifted nasopharyngeal swab if necessary. The third thread of the tampon without tension is placed between the cheek and gum of the lower jaw and fix its end with a strip of adhesive tape on the cheek or in the ear region on the side of the tamponade. For this thread, a tampon is removed from the nasopharynx after preliminary untying or cutting the “bow” and removing the front tampons. It is advisable to soak a nasopharyngeal swab with antibiotics, as well as hemostatic drugs. It should be, like other tampons, oiled with liquid paraffin. In order to avoid infection, tampons in the nasal cavity are kept for 2 days. A longer stay of tampons in the nasal cavity and in the nasopharynx is fraught with the development of sinusitis and otitis media. If necessary, especially in the military field, leaving tampons in the nose and nasopharynx for a longer time - in addition to the general antibiotic therapy, you should regularly irrigate the tampons with antibiotic solutions. In these cases, in the absence of signs of inflammation of the paranasal sinuses and middle ear, tampons can be left for up to 7-8 days.
All types of nasal tamponade end with the application of a horizontal one (Fig. 2.5.6), and when the back of the nose is wounded, a vertical sling bandage (Fig. 2.5.7).
Finishing the technical description of the considered types of nasal tamponade, it should be noted that there are no "trifles" when carrying them out. Neglecting each seemingly insignificant detail (non-observance of the correct position of the patient’s head, improper choice of the nasopharyngeal swab, tying the threads over the “anchor” to the “knot” rather than the “bow”, cutting the third thread designed to remove the swab from the nasopharynx, etc. ) fraught with serious consequences. The patient continues and even intensifies bleeding. Every minute, his condition is aggravated, especially in people of an older age group, weighed down by diseases of the cardiovascular system and blood diseases, or by a serious injury. You must always remember that stopping nosebleeds is a responsible business, requiring the doctor not only agility and speed, but also full concentration and punctuality, subject to all details of the tamponade.
Currently, abroad and in our country (Markov G.I., Kozlov V.S., 1990), industrial designs of pneumatic tampons have been proposed, which, however, have not yet found wide application. Pneumatic swab proposed by domestic authors Markov G.I. and Kozlov BC (the so-called "YaMiK" - from the first letters of the authors and the city where it was made - Yaroslavl) has a wider scope in rhinology, as it is also used in the treatment of inflammatory diseases of the nose and paranasal sinuses.
Surgical methods of stopping nosebleeds.
Used with the inefficiency of tamponade and recurrent nosebleeds. In order to obliterate the vessels with the mucous membrane of the nasal septum, various sclerosing preparations are used, for example, 0.5-1 ml of 5% quinine hydrochloride solution (Likhachev A.G., 1963; Nevsky B.N., 1976).
Most often, with repeated nosebleeds from the anterior nasal septum, the mucous membrane is detached in the bleeding area, followed by tamponade.
If the source of nosebleeds is the ethmoid arteries (branches of the internal carotid artery), endonasal dissection of the ethmoid labyrinth on the bleeding side is possible. After opening the lattice cells, the resulting cavity is tightly plugged. A method for clipping the ethmoid arteries on the medial wall of the orbit by the approach through the medial paraorbital incision is described.
In the case of persistent bleeding coming from the pool of the external carotid artery, it is possible to clip the jaw artery with the approach through the maxillary sinus.
Among the methods for stopping nosebleeds by ligation of the main vessel, the most common is ligation of the external carotid artery (provided bleeding originates from a vessel belonging to its pool).
Ligation of the external carotid artery - a serious surgical intervention that requires sufficient surgical preparation and knowledge of the topographic anatomy of the neck - is described in the relevant manuals. We only note that the most common approach to the external carotid artery is along the front edge of the sternocleidomastoid muscle (the so-called "classic approach"). However, it is convenient primarily for access to the internal jugular vein and common carotid artery. Meanwhile, back in 1886, at the Department of Operative Surgery of the Military Medical Academy, E.G. Salishchev, assistant professor. I.I.Nasilova, the most rational approach to the external carotid artery was developed, which is known in the literature as the Nasilov approach. Its peculiarity is an incision that starts from the lower jaw, retreating 2 cm anteriorly from its angle, and continues vertically down to the intersection with the sternocleidomastoid muscle. This incision corresponds exactly to the course of the external carotid artery. EG Salischev also established her permanent topographic and anatomical landmark - the location of the artery posterior to the capsule of the submandibular salivary gland. An ardent supporter of this approach was a major domestic ENT oncologist D.I. Zimont (1957).
The successes of endovascular neurosurgery allow in severe cases, after preliminary angiography and the establishment of a source of bleeding, to perform intravascular balloonization of the damaged vessel and turn it off from the bloodstream (V.A. Khilko).
Наряду с описанными способами остановки носового кровотечения, при значительной кровопотере, прибегают к гемостатической терапии, переливанию крови и кровезаменяющих жидкостей по правилам общей и военно-полевой хирургии. Кроме того, при повышенной местной фибринолитической активности, А. Н. Власюк (1970) и И.А.Курилин с соавт. (1976) рекомендуют пропитывать тампоны 3% раствором аминокапроновой кислоты - ингибитора фибринолиза.
Необходимо иметь в виду, что у больных, страдающих теми или иными общими заболеваниями, носовое кровотечение возникает в результате нарушения известного равновесия (гомеостаза), имевшего место, несмотря на наличие общего хронического заболевания. Поэтому, наряду с общими и местными мероприятиями по остановке кровотечения и компенсации кровопотери, необходимо приложить усилия для устранения (смягчения) причин, вызвавших носовое кровотечение.
Назначение седативных средств, успокаивающих психику больного, потрясенного кровопотерей и мероприятиями по остановке кровотечения, крайне желательно, как и создание благоприятного психологического климата вокруг больных этого профиля, часто находящихся в критическом положении.
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The outflow of blood from the anterior nasal openings or nasopharynx can occur without a visible external cause - the so-called spontaneous nosebleed. In addition, it can be traumatic and postoperative. Spontaneous nosebleeds cause general and local causes. Among the common, the most common are diseases accompanied by an increase in blood pressure
- Nose bleed
Epistaxis is a consequence of trauma, swelling of the nose, arterial hypertension, and hemorrhagic diathesis. Often there are nasal diseases in acute respiratory diseases, flu. Tactics depend on the etiology of bleeding and are aimed at eliminating the underlying cause. Местно в легких случаях прижимают края носа к перегородке и вводят в носовой ход кусочки ваты или марли,
- Nose bleed
Bleeding from the nose (epistaxis) is a symptom of local damage to the nose or general disease, so the causes of nosebleeds are divided into local and general; treatment is usually consistent with this division. Bleeding from other parts of the respiratory tract is much less common than from the nose. The source of nasal hemorrhages can be in different parts of the nose, but most often
- Nose bleed
The outflow of blood from the nose can be spontaneous (due to general or local pathological processes), traumatic or postoperative. Local causes of spontaneous bleeding from the nose include damage to a small area of the mucous membrane in the area of the nasal septum in its anterior lower part. The abundance of blood vessels in this area causes frequent bleeding, not only with injuries,
DIAGNOSTICS Based on the presence of nosebleeds. When the head is thrown back - blood draining along the back wall of the oropharynx or its lateral surfaces, coughing up clots and fresh blood. Possible vomiting of blood with clots. There are bleeding from the anterior (85% of cases) and posterior parts of the nasal cavity. Minor to massive bleeding, with signs of acute
- Nose bleed
Epistaxis, a clinical symptom of a general or local pathological process, is manifested by the release of non-foaming blood from the nostrils or by draining it along the back of the throat. Patients with nosebleed account for 3% of the total number of patients hospitalized in the ENT department. ETIOLOGY AND PATHOGENESIS The causes of nosebleeds (Table 9-1) are divided into local and general (systemic). Table
- Nose bleed
Epistaxis is more often caused by damage to the vascular plexuses of the anterior part of the nasal septum (Kisselbach region). Symptomatic bleeding is possible with hemorrhagic diathesis (thrombocytopenia, including with leukemia, thrombocytopathy, hemophilia), with infectious diseases (SARS, flu, sepsis, etc.), with local inflammatory and productive processes (polyps, adenoids,
D - ka: The presence of bleeding from the nasal opening. When head is thrown back - coughing up clots and fresh blood, blood swelling along the side or back wall of the oropharynx along a small tongue. Vomiting of dark blood and clots, pallor of the skin. Difficulty or disabling nasal breathing through one or both halves of the nose. When freezing - the allocation of clots with an admixture of fresh
- Nose bleed
Bleeding from the nose is a symptom of a local nose lesion or general disease. The most common bleeding area is the anteroposterior section of the nasal septum (Kisselbach zone): in most cases, bleeding from this area is not heavy, usually not threatening the patient’s life. Among the causes of nosebleeds are trauma, surgical interventions, benign and malignant
- Носовые кровотечения. Etiology. Методы остановки
Features of the structure and blood supply to the nasal mucosa cause exceptional bleeding in this area and the frequency of nosebleeds. Etiology: 1. Local causes: • Traumatic injuries (including surgical); • Foreign bodies of the nose; • Malignant tumors; • Atrophic processes in the nasal cavity; • Bleeding
- NOSE BLEEDING STOP KIT
1. Nose forceps 1 pc. 2. Ear tweezers 1 pc. 3. Nasal mirror 1 pc. 4. Turunda wide 20 ml 5. Adrenaline 0.1% solution 20 ml 6. Ephedrine 3% solution 20 ml
- OBSTETRIC BLEEDING (CONTINUED) BLEEDING IN THE EARLY POST-PERIOD PERIOD
Causes of bleeding that develops in the early postpartum period: 5. delayed parts of the placenta 6. soft birth trauma 7. impaired uterine contractility: - hypotonic bleeding - atonic bleeding 8. development of DIC. Retention of parts of the placenta. - occurs when the third period of labor is unreasonably active.
- Bleeding in gastric ulcer as an example of bleeding from the upper gastrointestinal tract
Gastric and duodenal ulcers cause about 50.% of cases of bleeding from the upper gastrointestinal tract (Table 9-2). Despite the introduction of new effective methods of treating peptic ulcer in the past 15 years, the frequency of bleeding with this pathology has not practically decreased. One of the reasons for this situation is the fact that often peptic ulcer
- OBSTETRIC BLEEDING (CONTINUED) COAGULOPATHIC BLEEDING (DIC-SYNDROME).
The process of blood coagulation constantly occurs in the body, but it is local, balanced in nature. Normally, there is a constant dynamic equilibrium with the fibrinolytic system. Excessive fibrinogen is captured by the cells of the reticuloendothelial system. DIC-syndrome (disseminated intravascular coagulation syndrome) is a pathological condition of hemostasis,
- The structure of the nasal cavity
The nasal cavity (cavum nasi) is located between the oral cavity and the anterior cranial fossa, and on the sides - between the paired upper jaws and paired ethmoid bones. The nasal septum divides it sagittally into two halves, opening anteriorly by the nostrils and posteriorly, into the nasopharynx, by the choanas. Each half of the nose is surrounded by four airy paranasal sinuses: maxillary,
- Examination of the nasal discharge.
First, the nostrils are examined (they can be narrowed or widened), and then they begin to study the nasal discharge by examination, smell and, if necessary, microscopy. In healthy animals, nasal discharge is either imperceptible, or it is released in very small amounts in the form of a serous or serous-mucous discharge, which is licked by the animal or removed by snorting. In the presence of
- HOSE AND NOSE
The previous two figures (Figs. 33 and 34) dealt with the nasal and oral cavities, as well as the blood supply to the head as a whole. Although you, I’m sure, can visualize the position of internal cavities from the surface of the head, you will undoubtedly experience more difficulties in visualizing the location and course of blood vessels. I could try to provide you with illustrations drawn from drugs,
- Examination of the nasal mucosa.
First, pay attention to the contours of the nasal openings and the presence of changes in them due to swelling of the skin, fractures of the nasal bones or neoplasms. Examine the mucous membrane of the nasal cavity with a simple examination or with the help of a nasal mirror, eye mirror, reflector, rhinoscope or laryngoscope. To examine the nasal mucosa, fingers capture the wings of the nose, open