Recurrent epistaxis, ICB code 10. Epistaxis - description, causes, symptoms (signs), diagnosis, treatment. When help is needed

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Nasal bleeding is bleeding from the inside of the nasal cavity or from the nasopharynx. It can appear in two places in the nasal region: in the anterior regions of the nose (this place is called kisselbach) and in the inferior turbinate of the anterior regions of the nose.

There is also posterior bleeding that occurs in the posterior portions of the nose and nasopharynx (the inferior concha or fornix). More often this condition occurs in children under 10 years of age and in people over 50 years of age.

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V international classification diseases (ICD-10) has its own code, which is named as follows: R04.0 Nosebleeds.

When such a problem arises, you need to know how to provide emergency care with nosebleeds to the patient, in order to help him as much as possible. The algorithm of first aid actions for nosebleeds will be as follows:

Before providing 1 relief for nosebleeds, it is estimated how much serious condition at the patient. It is necessary to immediately assess this phenomenon, whether it is possible to cope with blood loss on your own or you will have to wait for help from doctors.
Then you must initially calm down yourself and calm the victim. Asking the person to breathe deeply will reduce the emotional burden, lower the heart rate, and possibly prevent a spike in blood pressure. Since all these circumstances can aggravate the situation.
First aid for nosebleeds is performed in this way: it is more convenient to seat a person. It is important that the victim's head is tilted forward so that blood fluid flows out without obstruction.
The nostril from which bleeding is observed should be pressed against the septum and so it holds for several minutes. After these actions, a blood clot forms in the area of the damaged vessel.
Any vasoconstrictor drops from the Naphthyzin, Galazolin series, etc. will need to be dripped into the nasal passages. In each nasal section, 6-8 drops.
Then, in a few (8-10) drops, 3% hydrogen peroxide is dripped into both nasal openings.
You need to apply to the area of \ u200b \ u200bthe nose wet towel or other cold object. Such a compress is kept for 15-20 minutes, after which a pause is made for 3-4 minutes. The action is repeated up to 2-3 times.
Another way to provide first aid for nosebleeds is to immerse your hands in cool water and your feet in warm water. Due to this, the narrowing of the walls of the vessels occurs, and the blood fluid soon stops flowing out.

During the period of nosebleeds, the first health care is extremely important, the further state of the person will depend on it. If the condition was docked, then in the near future you should not drink hot drinks and eat hot meals, as well as intensively play sports. It is advisable to see a doctor if this has not already been done.

There are many reasons for nasal bleeding; external circumstances, local and general factors can contribute to this. It is worth considering the most common causes of nosebleeds.

External causes of nasal bleeding:

Poor humidity in the room, which causes dry air, especially in winter when the heating system in the house is on.
Overheating of the body.
Atmospheric changes or barometric changes, this can occur when climbing up or diving to depth.
The impact of toxic or poisonous substances on the body, when working in hazardous enterprises.
Taking certain types of medications.
Inhalation of drugs, especially cocaine.

Local causes of nosebleeds:

Nasal injuries.
ENT disease.
If there is a curvature of the nasal septum, there are vascular disorders, the layer of the mucous membrane in the nasal cavity is changed.
A tumor process in the nose - adenoids or polyps. Quite rarely, these are malignant growths such as sarcoma or carcinoma.
Penetration of a foreign object into the nasal passage, or various insects, etc.

Head position when nosebleeds occur

Common causes of frequent nosebleeds in adults:

Fragility of blood vessels due to changes in their walls, as a result of diseases such as vasculitis, vascular atherosclerosis, various infections, lack of vitamins.
Hormonal disorders.
Hypertension. Diseases such as atherosclerosis, heart disorders, chronic pyelonephritis, adrenal diseases, etc.
Blood pathologies. This poor clotting, anemic condition, leukemia, low level platelets.
Cirrhosis of the liver.

The reason should be found out through a comprehensive examination of the body, a blood test and a coagulogram must be taken.

Why only one nostril?

Bleeding from one nostril in adults also occurs as a result of various causes, they can be local and general.

Local factors affecting the occurrence of bleeding from one nostril:

trauma to the internal nasal structure;
the need to be under the scorching sunlight for a long time;
inflammation that has developed in the nose;
all kinds of tumors such as polyps, angiomas, papillomas and granulomas, sometimes sarcomas, which are cancerous.

Common reasons:

hypertension;
SARS, flu and other colds;
hemorrhagic diathesis, hemophilia;
due to specific working conditions, for example, this phenomenon is often found among pilots, divers, high-altitude climbers, etc .;
spleen or liver disease.

If the nose is bleeding heavily

It so happens that blood goes so much that it is difficult to stop it, usually this happens as a result of damage to the vascular wall.

profuse bleeding from the nose threatens with significant blood loss, and can even be fatal;
about 20% of the population suffering from this pathology needs emergency medical care;
anterior bleeding is considered the most harmless bleeding, it occurs in 90-95% of people;
arterial hypertension is one of the most common causes of nasal bleeding;
in 85% of cases, this symptom occurs against the background of general pathological causes, and only in 15% of cases, nosebleeds develop due to a disruption in the functioning of the organ itself.

What It Says: Signs and Symptoms

Anterior bleeding is characterized by the formation of blood in the front of the nose.

In the posterior view, the deeper parts of the structure of the nose are involved. Sometimes the nosebleeds do not flow as it flows down the throat. As a result, following symptoms:

Nausea.
Vomiting with blood impurities.
Hemoptysis.
The stool is tarry, that is, black, this is due to the fact that the blood, under the influence of digestive enzymes, acquires a resinous hue.

The symptoms of this condition will depend on the amount of blood loss.

If the blood loss is not so significant (up to several milliliters), the person's general well-being does not change. The exception is suspicious persons, or people who are afraid of blood, they may develop fainting or hysteria.

If the bleeding is prolonged, then over time, the following signs appear:

general weakness;
flies appear before the eyes;
feeling thirsty;
dizziness;
fast heartbeat;
blanching of the skin and mucous membranes of a person;
development of shortness of breath.

If the blood loss rate is already 20%, then hemorrhagic shock may develop, which manifests itself as follows:

lethargy in consciousness;
frequent heart beats;
a threadlike pulse is felt;
horse racing blood pressure which subsequently lead to its decrease;
a decrease in the amount of urine or it is completely absent.

Blood from the nose in pregnant women can be observed both at the beginning and at the end of bearing a child, only the reasons for this circumstance may be different. In the first trimester, this condition may be due to physiological changes in the woman's body. There is a relationship with elevated progesterone, a hormone that is responsible for the maintenance and normal development of pregnancy.

Due to the action of progesterone, blood flow increases in the entire system of a pregnant woman. Sometimes small capillaries cannot withstand such pressure and rupture, for this reason epistaxis may develop.

After 20 weeks of pregnancy, a complication such as gestosis may develop, in which pressure on the arteries increases, which leads to the appearance of blood from the nose. Other factors affecting the frequent discharge of blood from the nose are characterized by a lack of vitamins and micronutrients, trauma, drying out of the nasal mucous membranes, and poor blood clotting.

The child's body is extremely susceptible to nosebleeds, the reasons for this are as follows:

A blow to the nose or mechanical action on the mucous membrane of an organ. It is not uncommon for a child to stick his fingers in his nose or try to shove any small object into his nostrils.
Defects in the structure of the nose of an anatomical nature.
Bacterial or viral infections.
Weakening immune system, vitamin deficiency.
Thermal or chemical burns.
Overheat.
Various pathologies, often hemophilia, liver and spleen abnormalities, tumor process in the nasal cavity.
Dryness in the room.

In transitional age, the child's body undergoes changes, both anatomical and physiological. The appearance of blood from the nose is often not associated with disease. After the end of adolescence and puberty, everything will return to normal.

Regular nosebleeds in a child should not leave his parents indifferent, it is imperative to consult a doctor for advice.

Causes of nosebleeds during adolescence:

getting an injury or bruised nose as a result of a fight, game or accident;
various growths, for example, cystic formations, polyps and adenoids;
the septum of the nose can be deviated from birth or have an acquired character;
weakening of the capillary walls due to increased physical load, overheating, hypothermia, etc.

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A few words about the features of the blood supply to the nasal cavity:

Conclusion

All of the above reasons should be established by the doctor after diagnostic measures.
If necessary, therapy will be prescribed that will relieve the person of frequent nosebleeds.
Do not forget that there are many reasons for nosebleeds and not all of them are harmless, sometimes such a condition can serve as a symptom of dangerous pathologies.

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ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Ministry of Health of Russia dated 05/27/97. No. 170

A new revision (ICD-11) is planned by WHO in 2017 2018.

As amended and supplemented by WHO

Processing and translation of changes © mkb-10.com

ICB code 10 nosebleeds; causes

At least once in a lifetime, everyone experiences such a nuisance as nosebleeds. It often happens that in young children, nosebleeds begin to flow "out of the blue." However, there are still reasons for this phenomenon, and there are quite a few of them. If your child has nosebleeds often, 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

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

Nosebleeds, the ICD code 10 of which is R04.0, can 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 ailment is damage to the vessels of the mucous membrane of the nasal cavity, which occurs as a result of the following:

Injuries to the nose: external (bruise, fracture), internal (injury with a finger, nail, pencil, small object that got into the nose).
Inflammation of the nasal mucosa (sinusitis, adenoiditis, rhinitis).
Dry areas of the nasal mucosa.
Operations in the area of the nose and various medical procedures.
Polyps, tumors, tuberculous ulcers in the nose.
Thinning of the mucous membrane due to a violation of its nutrition (curvature of the nasal septum, atrophic rhinitis).
Increased blood pressure.
High body temperature.
Deficiency of vitamin C, K, calcium
Sunstroke or heatstroke.
Influenza and other infectious diseases.
Liver disease, hepatitis.
Sudden changes in atmospheric pressure and excessive physical exercise.
Hormonal changes in adolescence.
Dust, tobacco smoke, animal hair.
Too dry or hot air in the room where the child is constantly.
Severe stress.
Violation of blood circulation, blood clotting.
Internal trauma.

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 depletion 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. With 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 bleeding in a child in order to avoid unpleasant consequences.

Relief for nosebleeds: algorithm

For nosebleeds in a child, proceed as follows:

Sit down 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, do not peep to check if the blood is coming or not. Try to hold out in this position for exactly 10 minutes.
It is advisable to apply cold to the bridge of the nose, for example, ice cubes. You can give your child something cold to eat or drink (ice cream, cold juice through a straw).

In no case should you do the following:

Do not throw the baby's head back, as this will cause blood to flow down the back of the nasopharynx, and the baby may choke if there is a lot of blood.
Do not shove cotton wool, tampons, or anything else into your child's nose as a "plug". The blood will dry up and bleeding will start again when you remove the tampon.
Do not let your baby lie down, as severe bleeding and vomiting may cause the baby to choke.
Do not allow your child to talk or move as this may worsen the bleeding.

When to call a doctor

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

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

With frequent bleeding (once 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.

Ascorutin for children with nosebleeds: dosage

Ascorutin is vitamin preparation containing vitamins C and P. This remedy is recommended for both children and adults, especially during seasonal outbreaks infectious diseases and flu. It is also great for prophylaxis 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 density and elasticity blood vessels.

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

Ascorutin is prescribed for children over 3 years old, should be taken only after consulting a doctor, since the drug has certain restrictions and contraindications, as well as allergic reactions and side effects... Price for this drug accessible to all segments of the population.

Causes of nosebleeds in children

Nosebleeds in adults; causes and treatment

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R04.0 Epistaxis

What is Nosebleeds -

primary, due to local processes;
symptomatic associated with common reasons(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 posterior wall of the pharynx and is swallowed, less often aspirated).

What provokes 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 antero-inferior cartilaginous part of the nasal septum (Kisselbach point), formed by the branches of the nasopalatine artery, its anastomoses and a powerful venous network of dilated vessels; all arteries supplying this area with blood pass here into the venous network. Frequent bleeding in this area is caused by cavernous tissue with poorly developed muscles, dense attachment, thinner and less extensible mucous membrane in this section.

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

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

Among the local causes, various exogenous and endogenous factors play a role:

injury to the nose when hitting, falling;
surgical interventions;
bad habit of picking your nose;
foreign bodies the nasal cavity (at the time of introduction into the mucous membrane and as a result of their prolonged 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;
curvature of the nasal septum;
diphtheria and tuberculous ulcers;
chemical, thermal, radiation and electrical burns of the nasal cavity.

Symptoms of Nosebleeds:

Hemorrhagic discharge from one or both halves of the nose, blood drainage along the back of the pharynx are noted.

Possible bloody vomiting or blood in the sputum when coughing against the background of general weakness, a drop in pulse and blood pressure, fainting with hidden bleeding.

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

Diagnosis of Nosebleeds:

With nosebleeds, the diagnosis is made without much difficulty. Children are very sensitive to blood loss, therefore, frequent repeated even minor nasal bleeding requires careful examination of the child and appropriate treatment.

Treatment for Nosebleeds:

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

The hemoglobin level may be overestimated due to thickening of the blood with massive bleeding.

Bleeding from the anterior nasal septum is relatively easy to control.

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

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

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

One of effective methods is a detachment of the mucous membrane and perichondrium in the area of the bleeding area in order to desolate the vessels and scarring.

At the same time, general action is taken, drugs are prescribed that increase blood clotting: they give calcium chloride and ascorbic acid orally, intramuscularly vikasol, calcium chloride, calcium gluconate, hemophobin, epsilon-aminocaproic acid are administered intravenously. In severe cases, transfusion of blood, platelet mass, hemodesis, rheopolyglucin is performed. Liver extracts are used in the form of hepatocrine or campolon (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 the life of the patient is presented by 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 are unsuccessful, 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 placed in layers from the bottom up along the entire length of the nasal cavity between the turbinates and the nasal septum. The tampon is removed in one hour after soaking it with isotonic sodium chloride solution or 3% hydrogen peroxide solution to reduce trauma to the nasal mucosa and avoid re-bleeding. A tampon left in the nose for a longer period can lead to sinusitis or otitis media. If it is necessary to leave the tampon in the nasal cavity for a longer time, soak it with an antibiotic solution or repeat the anterior tamponade 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 swab with three threads according to the size of the nasopharynx, equal to approximately two nail phalanges thumb hands of a child. A gauze swab is inserted into the nasopharynx through the oral cavity. Preliminarily, a thin elastic catheter is passed into the nasopharynx along the lower nasal passage. When the end of the catheter goes into the mouth of the pharynx, it is grasped with a forceps or a Kocher forceps, 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 choanae.

The end of the thread coming out of the mouth is fixed with an adhesive plaster to the cheek.

The posterior nasal tamponade 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 does not descend down into the oropharynx. The tampon should not be left in the nasopharynx for more because of the risk of infection spreading through the auditory tube into the middle ear with the development of otitis media, and also through the ethmoid plate into the anterior cranial fossa. From the nasopharynx, the tampon is removed using the end of the thread extending into the oral cavity, after removing the anterior tampon.

It should be borne in mind that spontaneous nosebleeds in patients with hypertension refer to hypercoagulable, caused by coagulopathy of consumption due to an increase in the anticoagulant activity of blood and lysis of loose clots, a decrease in vascular resistance, dysfunction of platelets, the formation of complex compounds of heparin. In this regard, when they stop their nosebleeds in complex therapy use hypocoagulants under the control of thrombo-elastogram (anticoagulants indirect action- dicumarin, nitropharsin, phenylin).

In case of 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 is also used to stop them. medial wall.

If general and local hemostatic measures are unsuccessful, with intense, life-threatening bleeding, the external carotid arteries are ligated.

Nosebleeds: symptoms and causes

Epistaxis is the discharge of blood from the cavity of the nose through the nostrils. Occurs in more than half of the population, frequent nosebleeds usually occur between the ages of 10 and over 50. And they are found in males, in comparison with females, much more often. Sometimes the blood is not released outside, but into the oral cavity, and then enters the stomach. Occurs more often at night.

Nosebleeds - causes

Almost everyone has experienced nosebleeds throughout their lives. But not everyone knows why it happens. The code R04.0 was assigned to the ICD 10 for nosebleeds. Often the 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 ones.

Local provoking factors include:

Injury - injuries of the nasal mucosa, provoked by the ingress of a foreign object, injuries after surgery
diseases that provoke supersaturation of nasal mucosa with blood - rhinitis of acute and chronic forms, 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:

CVS diseases - heart disease, atherosclerosis
increased 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)
changes in blood clotting
violation of the menstrual cycle (vicarious hemorrhage from the nose)

Symptoms

The main signs of nosebleeds - discharge bleeding from the nostrils outward or through the nasopharynx into oral cavity... If the hemorrhage occurs at night, you can swallow the bleeding during sleep. Therefore, in emetic or feces bleeding can be detected. If the syndrome is caused by the presence of a disease, the patient is diagnosed with the symptoms of the one that provoked the disease.

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

A person may be disturbed by 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 diagnose "nosebleeds". The doctor fills out a medical history, in which the disease is assigned the R04.0 code according to the microbiology 10. The medical history includes the patient's complaints, symptoms, patient data. Due to the fact that epistaxis can cause various diseases, the medical history is carefully studied by the doctor, it turns out why the syndrome arose.

If the doctor suspects that the patient has blood or cardiovascular diseases, 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 origin, can be:

Anterior nosebleeds are usually of 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 other hand, are characterized by a large volume of hemorrhage and can harm human health. The patient may complain about 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 its own. That is why it requires timely provision of emergency care and the use of special methods to stop it.

The degree of blood loss

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

An insignificant stage - is released from a couple of drops to a couple of milliliters of blood discharge. It does not threaten human health and life, 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 blood no more than 700 ml. A person may feel the following symptoms - dizziness, pallor of the skin, increased heart rate.
Medium - 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 medical assistance is required:

great blood loss
hemorrhage is triggered by trauma to the nasal cavity
fever and headache
the 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 the person with peace, help him 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, since this process does not allow clogging of the damaged vessel with blood clots and elimination of hemorrhage. Cold is applied to the bridge of the nose (container with ice). This will help narrow blood vessels and stop epistaxis.

If nosebleeds are not too abundant, it is necessary to carefully press the wings of the nose to 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, pre-moistened with a 3% hydrogen peroxide solution. If epistaxis has caused overheating, the victim must be moved to the shade.

Preventive measures are aimed at:

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

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Nose bleed

Definition and background [edit]

Epistaxis occurs at least once in every fifth person's life. It is most common in middle-aged men.

Etiology and pathogenesis [edit]

The most common reasons nosebleeds - trauma, surgery (surgical interventions on sinuses nose, conchotomy, rhinoplasty, plastic nasal septum) 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 drop in atmospheric pressure (for example, in an airplane).

Nosebleeds are usually short-lived and easy to stop. Severe bleeding that does not respond to treatment simple methods are less common. They can lead to massive blood loss, arterial hypotension, cardiovascular disorders.

Clinical manifestations [edit]

Epistaxis: 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 antipyretic drugs interfere with platelet function. Aspirin and drugs containing aspirin (Alka-Seltzer, Perkodan, Talvin, etc.) suppress platelet aggregation and can provoke bleeding.

Diseases of the blood (leukemia, anemia, hemophilia, erythremia, lymphoma), liver disease, chronic renal failure, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) can be accompanied by severe nosebleeds. Family history is taken to identify coagulopathies; determine the bleeding time, APTT and PT; 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 less common causes of nosebleeds. Recurrent bleeding from one side of the nose, combined with difficulty in nasal breathing, pain, and swelling of the face suggests nasal or sinus swelling. An examination of the nasal cavity and, if possible, CT is performed. For rhinoscopy, a fibroscope is used.

Bleeding can occur in the anterior (80-90% of cases) or posterior parts of the nasal cavity. To identify the bleeding area, good lighting (headlamp or frontal reflector), vision (nasal mirror) and suction (Frazier tip) are needed. The forehead illuminator allows the clinician to simultaneously manipulate the nasal speculum and suction. For anesthesia, narrowing of blood vessels and drying 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 introduced into the nasal cavity. The tampon 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 (nasal septum plasty, rhinoplasty, etc.), nasal tamponade may negate its results. In this case, you must immediately notify the surgeon who operated on the patient. If bleeding occurs after plastic surgery on the septum, he will most likely have to remove the hematoma formed between the muco-perichondral 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 nasal cavity, 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's zone). Bleeding can be venous or arterial. At arterial bleeding, which is much less common than venous, a pulsating damaged artery is visible.

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

B. After processing vasoconstrictor and a local anesthetic can localize and cauterize the bleeding area. Cauterization is carried out with a probe, on the head of which silver nitrate is soldered. The bleeding area (2-4 mm in diameter) is carefully treated, trying not to touch the surrounding tissues and the bottom of the nasal cavity. The preliminary narrowing of the vessels of the mucous membrane reduces discharge from the nose and prevents the spread of the cauterizing agent. Bipolar diathermocoagulation minimizes damage to surrounding tissues. Particular care is taken not to damage the edge of the nostril. Can be used laser coagulation(carbon dioxide laser, wavelength tunable liquid dye laser), but this method requires special skills.

D. If moxibustion is impossible or it did not have an effect, resort to anterior tamponade of the nose with gauze turunda. Turunda is impregnated with an antibiotic ointment. Hemostatic plates (eg Surgicel) soaked in bacitracin ointment can be used. The plate is applied to the bleeding area and a gauze turunda is laid on top of it in layers. The pressure on the bleeding area must be strong enough. For the prevention of sinusitis, antibiotics are prescribed (ampicillin, 250 mg orally 4 times a day). The tampon 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 nasal cavity

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

B. If, after the anterior tamponade, blood continues to flow into the pharynx, the source of bleeding is in the posterior sections. Most often these are wedge-palatine 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 nasal septum surgery, bleeding from a dissected bone or septum may occur. After endoscopic sinus surgery, the injured nasal mucosa may bleed.

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

D. The 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 mucous membrane of the nose and the back of the pharynx 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 choanae. Then an anterior nasal tamponade is performed with gauze turunda soaked in antibiotic ointment. The back tampon acts as a shutter 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 an adhesive plaster on the cheek. The classic method of posterior nasal tamponade is a complex procedure; it should be performed by a physician familiar 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 introduced 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 choanal lumen, add physiological saline to the balloon. Then an anterior nasal tamponade is performed with gauze turunda soaked in antibiotic ointment. The bloated 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.

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

G. After the posterior nasal tamponade, the patient is hospitalized. Sedatives, antibiotics, oxygen inhalation are prescribed. With complete obstruction of the nasal passages, breathing is carried out only through the mouth, therefore hypoventilation and a decrease in pO 2 are possible. The patient is closely monitored: hypoxia, toxic shock, renewed bleeding are possible. Epistat contoured balloons allow breathing through the nose due to the presence of a central channel, therefore, after the bleeding has stopped, the patient can be released home under the supervision of the attending physician.

H. In case of repeated or persistent nosebleeds, when the tamponade of the nose is ineffective, ligation of a large vessel is indicated. When bleeding from the posterior nasal cavity, the branches of the maxillary artery are ligated (approach through the posterior wall of the maxillary sinus). Another method is to ligate the external carotid artery above the origin of the superior thyroid artery; it is less effective due to its well-developed collateral circulation... With persistent bleeding, the source of which is located above the middle turbinate, 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. With persistent nosebleeds, if the ligation of the vessel was ineffective, angiography and embolization of the maxillary artery are indicated. With the help of angiography, it is possible to establish the cause of the ineffectiveness of the ligation: the presence of collateral circulation or anastomoses between the maxillary and ethmoid arteries. Embolization can be performed multiple times.

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.

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 supersaturation of nasal mucosa with blood - rhinitis of acute and chronic forms, 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:

CVS diseases - heart disease, atherosclerosis
increased 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)
changes in blood clotting
violation of the menstrual cycle (vicarious hemorrhage from the nose)

Symptoms

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

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

A person may be disturbed by 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 blood or cardiovascular diseases, 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 origin, can be:

front
rear

Anterior nosebleeds are usually of 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 other hand, 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 its own. That is why it requires timely provision of emergency care and the use of special methods to stop it.

The degree of blood loss

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

An insignificant stage - is released from a couple of drops to a couple of milliliters of blood discharge. It does not threaten human health and life, 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 blood no more than 700 ml. A person may feel the following symptoms - dizziness, pallor of the skin, increased heart rate.
Medium - 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 medical assistance is required:

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

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

Preventive measures are aimed at:

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

Distinguish bleeding:

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

What provokes nosebleeds:

Common Causes nosebleeds are caused by diseases of organs and body systems:

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

Among local causes various exogenous and endogenous factors matter:

injury to the nose when hitting, falling;
surgical interventions;
bad habit of picking your nose;
foreign bodies of the nasal cavity (at the time of introduction into the mucous membrane and as a result of their prolonged 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;
curvature of the nasal septum;
diphtheria and tuberculous ulcers;
chemical, thermal, radiation and electrical burns of the nasal cavity.

Symptoms of Nosebleeds:

Hemorrhagic discharge from one or both halves of the nose, blood drainage along the back of the pharynx are noted.

Possible bloody vomiting or blood in the sputum when coughing against the background of general weakness, a drop in pulse and blood pressure, fainting with latent bleeding.

Diagnosis of Nosebleeds:

Treatment for Nosebleeds:

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.

The hemoglobin level may be overestimated due to thickening of the blood with massive bleeding.

Bleeding from the anterior nasal septum is relatively easy to control.

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

To stop bleeding, a hemostatic sponge, tampons with 1% feracryl solution, epsilon-aminocaproic acid, canned amnion, 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 desolate the vessels and scarring.

Anterior nasal tamponade is performed when bleeding from the anterior parts of the nose. A sterile gauze swab impregnated with a hemostatic composition is placed in layers from the bottom up along the entire length of the nasal cavity between the turbinates and the nasal septum. The tampon is removed 24-48 hours after soaking it with isotonic sodium chloride solution or 3% hydrogen peroxide solution to reduce trauma to the nasal mucosa and avoid re-bleeding. A tampon left in the nose for a longer period can lead to sinusitis or otitis media. If it is necessary to leave the tampon in the nasal cavity for a longer time, soak it with an antibiotic solution or repeat the anterior tamponade 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 swab with three threads according 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. Preliminarily, a thin elastic catheter is passed into the nasopharynx along the lower nasal passage. When the end of the catheter goes into the mouth of the pharynx, it is grasped with a forceps or a Kocher forceps, 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 choanae.

The end of the thread coming out of the mouth is fixed with an adhesive plaster to the cheek.

The posterior nasal tamponade 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 does not descend down into the oropharynx. The tampon should not be left in the nasopharynx for more than 1 - 2 days due to the danger of infection spreading through the auditory tube into the middle ear with the development of otitis media, as well as through the ethmoid plate into the anterior cranial fossa. From the nasopharynx, the tampon is removed using the end of the thread extending into the oral cavity, after removing the anterior tampon.

It should be borne in mind that spontaneous nosebleeds in patients with essential hypertension are hypercoagulable, caused by coagulopathy of consumption due to an increase in the anticoagulant activity of blood and lysis of loose clots, a decrease in vascular resistance, dysfunction of platelets, the formation of complex heparin compounds. In this regard, when they stop nasal bleeding in complex therapy, hypocoagulants are used under the control of thrombo-elastogram (indirect anticoagulants - dicumarin, nitropharsin, phenylin).

If general and local hemostatic measures are unsuccessful, with intense, life-threatening bleeding, the external carotid arteries are ligated.