NASAL BLEEDING (epistaxis) — release of blood from outside openings of a nose or through a nasopharynx. N to. can be insignificant, in the form of drops, and plentiful (profuse), short-term and long, single and repeated, recuring through various time terms. N to. on frequency wins first place among spontaneous bleedings from upper respiratory tracts. It happens at any age, a thicket during puberty and 55 years, especially at men are aged more senior. During the winter and spring periods of year N. to. meets more often that connect with a hypovitaminosis.
N.'s Reasons to. conditionally divide into the general and local. The general reasons of N. to. there can be diseases, at to-rykh there is an increase in the ABP, disturbance of coagulant system of blood, increase in permeability of a vascular wall (atherosclerosis, a hypertension, hemorrhagic diathesis, Osler's disease — Randyu, leukoses, cirrhosis, inf. diseases, especially typhoid, brucellosis, scarlet fever, flu, malaria, and also hypovitaminoses, etc.). N to. it is observed at frustration of a menstrual cycle (so-called vicarious bleedings), at septic states, poisonings, intoxications, physical and mental tension, as a result of long stay in the sun. N. is frequent to. it is connected with jump of atmospheric pressure and partial pressure of oxygen (at pilots and climbers), etc.
To the local reasons of N. to. carry injuries of a nose, dryness of a mucous membrane, especially front departments of a nasal partition, benign and malignant tumors of a nose and its subordinate clauses (okolonosovy, T.) bosoms, disintegration of tubercular or syphilitic infiltrate of a mucous membrane of a nasal cavity, foreign bodys in a nasal cavity, etc. Contributing to N. to. can be the reasons acute and hron, cold, adenoides, sometimes curvatures, thorns and crests of a nasal partition, and also a strong smorkaniye, cough, sneezing.
A clinical picture
Usually N. to. arises at once, napr, after an injury of a nose or the head, sometimes without the reasons seen for the patient, even in a dream. N.'s harbingers to. there can be a headache, weakness, weight in the head, a sonitus, dizziness, an itch in a nose, etc. Bleeding from one half of a nose is in most cases observed, at the same time quite often blood through a nasopharynx flows also into other half. At the time of N. to. blood usually pure, bright red, not made foam. At the hidden N. to. a part of blood gets through a postnaris into a throat, a gullet and a stomach that creates dangerous illusion of wellbeing.
The general condition of the patient, indicators of the ABP, pulse rate, condition of cardiovascular system at N. to. depend first of all on volume and speed of a loss of blood (see. Blood loss ). Bystry blood loss sharply burdens a condition of the patient, leads to development collapse (see) up to a cardiac standstill. Easy (insignificant) N. to. occurs most often, at 80 — 90% of patients, and usually does not pose direct hazard to life. Sometimes it stops independently, but in some cases long time can last, causing falling of pulse, the general weakness in the patient and leading to anemia.
N to. moderately severe it is characterized not only local, but also general signs: blanching of face skin, increase of pulse to 90 — 100 ud. in 1 min., can go down several systolic pressure (to 90 — 100 mm of mercury.), the indicator of a hematocrit decreases (see. Gematokritny number ). At heavy N. to. the general serious condition, pulse becomes frequent to 110 — 120 ud. in 1 min. and more, systolic pressure falls to 80 mm of mercury. below. It should be noted that the hemoglobin content in blood directly after bleeding does not change, it goes down only in a day. A reliable indicator of volume of blood loss is the hematocrit.
Special the wedge, a picture is observed at heavy recurrent N. to. after injuries of a skull, it is frequent with changes of its basis. After such injury of N. to. repeats at a number of patients through long time terms (2 — 3 weeks), differs in massiveness (0,5 — 1,5 l and more) and speed of blood loss. It begins suddenly and proceeds usually several minutes. If not to take the appropriate measures, at one of such bleedings of the patient can die.
the Diagnosis does not present special difficulties, difficulties arise only during the definition of the place of bleeding and in cases of the concealed hemorrhages. At a lobby rinoskopiya (see) in the forefront of a nasal partition it is possible to see the bleeding place, a so-called sex of Kissel-bakh. This field of rounded shape, has in the diameter apprx. 0,5 — 1,5 cm and is located approximately on 1 cm otstupya from an entrance to a nose. It is determined by the thinned mucous membrane and the network of blood vessels translucent through an epithelium. Bleedings from Kisselbakh's field, as a rule, not plentiful.
Plentiful (profuse) N. to. in most cases happen from back departments of a nose that is explained by big caliber of the vessels which are located here.
Lech. tactics in each separate case is individual and depends on N.'s character to., the volume of blood loss, data a wedge, blood test, a koagulogramma, biochemical blood analyses, from the general condition of the patient. N.'s treatment to. includes the local stop of bleeding and the general actions directed to completion of volume of blood and liquid in a blood channel to necessary level, medicamentous impact on processes of a fibrillation, maintenance of vital signs of an organism (cardiovascular, respiratory, etc.), elimination of the reasons of N. to.
At insignificant N. to. a finger press a wing of a nose, but it is better to enter previously into a vestibule of the nose a lump of cotton wool, the dry or moistened 3% with solution hydrogen peroxide. On a nose bridge or on a nape within an hour cold for 3 — 4 min. with breaks also 3 — 4 min. is applied. It is not necessary to throw back the head of the patient since in this situation blood will flow down on a back wall of a throat. After such N.'s stop to. reasonablly prizhech the bleeding site of 50% solution of silver nitrate (or trichloroacetic, chromic to-tami). Sometimes cauterize the bleeding place a galvanocauter. At insignificant recurrent N. to. during remission cuts of a mucous membrane in front of and behind the bleeding site on a nasal partition with amotio of fabric between cuts are most effective.
At inefficiency of the described actions and the expressed N. to. most often make a front tamponade of a nasal cavity. After preliminary greasing of a mucous membrane of 3 — 5% solution of cocaine (or mix of 1% of solution of Dicainum from 0,1% solution of adrenaline) make a tamponade the gauze turundas impregnated with an iodoform or haemo static paste of Vasilyeva (streptocide and calcium chloride on 5,0; zinc oxide 10,0; gelatin 25,0; glycerin and distilled water on 50,0); also Derbenyova's emulsion is applied (tannin 5,0; ephedrine 0,1; salicylic to - that 1,0; lanolin 25,0; peach-kernel oil 40,0; lead acetate 10,0; distilled water 20,0), etc. The turunda is entered into a nasal cavity layer-by-layer, beginning from a bottom of a nasal cavity. Instead of a turunda it is possible to apply the elastic tampons prepared from surgical rubber gloves and foam rubber (put on a rubber finger a strip of foam rubber and sterilize). Enter from 2 to 5 such tampons into one half of a nose. Tampons delete from a nose usually in a day. At slowness of a hemostasis they are left for 2 — 5 days, at the same time it is reasonable to impregnate daily by an injection tampons of 40% with solution aminocaproic to - you, solution of an antibiotic, etc.
At N. to. moderately severe and heavy N. to. the front tamponade can be inefficient therefore quite often at once start a back tamponade of a nasal cavity. It is made in advance prepared sterile tampon (size about 2x3 cm) which is tied up by three strong silk threads 20 cm long. Rubber catheter (or tube) to dia. 2 — 3 mm carry out on a bottom of the bleeding half of a nose to a throat and, having taken its end a packer, remove through a mouth. Tie two threads of a tampon to the oral end of a catheter, then drag a catheter together with two threads in the opposite direction through a nose, and an index finger of the right hand enter a tampon for a palatine velum into the corresponding postnaris and slightly press down it with a simultaneous easy pandiculation for two threads which are coming out through a nose. After that make a front tamponade of the same half of a nose, at the end of a tamponade of thread tie at an entrance to a nose over the gauze roller. The third thread of a tampon which is coming out a mouth is pasted an adhesive plaster to a cheek or cut off at the level of bottom edge of a palatine velum. Delete a back tampon with a packer for this third thread. Depending on N.'s features to. the tampon is deleted, as a rule, in 2 — 3 days, in some cases it is in a nasopharynx up to 10 days. Sometimes, at severe bleeding from back departments of a nose when it is not possible to establish from what half (postnaris) of a nose bleeding, make a back tamponade of both half of a nose or enter the big tampon which is densely carrying out all nasopharynx. After a back tamponade for prevention of development tubo-otitis (see), acute average otitis (see), acute pharyngitis (see) appoint antibacterial agents and drugs. reducing hypostasis.
When bleeding does not manage to be stopped by means of a tamponade of a nose, operational treatment is shown. At N. to. make the following operative measures: submucosal resection of a nasal partition; total resection of a nasal partition; a vertical section of a mucous membrane in an average third of a share and a horizontal section parallel to an entrance to a nose; a scraping of the bleeding site; a submucosal resection of the bent sites of a nasal partition, crests, thorns; bandaging of the bringing (etmoidalny) arteries with approach through an eye-socket; bandaging of an internal maxillary artery in the field of a pterygopalatine pole with transmaksillyarny approach; bandaging of an outside carotid artery; bandaging of the general carotid artery (is a last resort).
From the general actions at easy and moderately severe N. to. make intravenous injection of 10 ml of 10% of solution of calcium chloride, 10 — 20 ml of 5 — 10% of solution gelatin, appoint vitamins.
With the haemo static purpose intravenous administration of a hydrocortisone on 30 mg 2 — 3 times a day within 3 — 4 days, 5% of solution aminocaproic to - you on 100 ml within 3 — 4 days (under control of a koagulogramma), 5% of solution of hydrosodium carbonate on 30 ml a day under control of acid-base equilibrium is shown. Appoint also inhalation of the moistened oxygen. One of the most effective haemo static drugs is blood. Hemotransfusion with the replaceable purpose is made usually only at rather bystry blood loss, but depending on indicators of blood pressure, frequency and volume of the previous bleedings the hemotransfusion can be shown at average and even easy degree of N. to. At N. to., caused by any disease, treatment is carried out it.
The forecast and Prevention
the Forecast in most cases favorable, especially at young faces. Plentiful and frequent N. to. can lead to secondary anemia.
Prevention. At the heart of N.'s prevention to. prevention and timely active treatment of the diseases leading to N.'s emergence to lies., and also diseases of a nose. To N.'s prevention to. fight against operational and household injuries, and also rational employment of patients taking into account these or those general diseases and diseases of a nose promotes.
Bibliography: Bokstein F. S. Intranasal surgery, M., 1956; Caspian Sea I. L. Anatomic and clinical data to a question of nasal bleedings from a kisselbakhov of the place, in book: Arkh. from-laringol., under the editorship of Ya. S. Temkin, t. 5, page 336, M., 1941; The Multivolume guide to otorhinolaryngology, under the editorship of A. G. Likhachev, t. 4, page 199, M., 1963; Nazarova G. F., etc. The organization of ambulance at LOR-diseases, Works of the 3rd Vserossiysk. congress otorinolar., page 59, M., 1974; E vans J. The etiology and treatment of epistaxis, J. Laryng., v. 76, p. 185, 1962; Wagner G. A. L. Epistaxis, J. Otelaryng., v. 7, p. 545, 1978.
V. T. Palchun.