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| Nose Bleeding |
1. Local reason
(1) nasal injury ? mechanical trauma such as car accidents, falls, hurt boxing dig nose, etc., are common causes of nosebleeds. ? barotrauma in high altitude, during a dive, if the pressure difference between the inside and outside sinus sudden change is too large, nasal sinus mucosa bleeding blood vessels to dilate. ? damage during radiation therapy of head and neck radiotherapy and after radiotherapy, nasal congestion and edema occur, or epithelium, nasal bleeding can occur.
(2) a deviated septum occurs in the bone or bone crest spines (rectangular shaped protrusion) near or convex deviated septum, where the mucous membrane is thin, the flow of the air stream changes here, so the mucous membranes become dry, so that rupture of blood vessels. Patients with nasal septum perforation exist, due to the perforated edges of dry mucous membranes, erosion and dry crazy off, can cause recurrent epistaxis.
(3) nasal inflammation ? nasal non-specific inflammation acute rhinosinusitis, dry rhinitis, atrophic rhinitis can lead to nose bleeding, bleeding generally small. ? nasal specific infected with TB, lupus, syphilis, leprosy and diphtheria specific infection, due to mucosal erosions, ulcers, granulation, nasal septum perforation can cause nosebleeds.
(4) the nasal cavity, paranasal sinuses and nasopharynx tumor most prone to nose bleeding hemangioma of the nasal septum, nasopharyngeal angiofibroma, hemorrhagic polyps and nasal sinus cancer. Small amount of nasal bleeding or tears in the blood is one of the main symptoms of early cancer.
(5) nasal foreign body is common in children, mostly unilateral epistaxis, nasal foreign body due to long-term retention in the nasal cavity, nasal mucosa erosion can cause hemorrhage. Animal nasal foreign body, such as leeches, can cause repeated a large nose bleeding.
2. Systemic reasons
(1) bleeding disorders and blood diseases ? vessel wall structural and functional deficiency diseases such as hereditary haemorrhagic telangiectasia, vitamin C deficiency, purpura, drug-induced vascular purpura, infection vascular purpura, vascular von Willebrand like. ? platelet count or functional disorders such as idiopathic thrombocytopenic purpura, various causes of secondary thrombocytopenia. ? clotting factor disorders, such as various types of hemophilia, vitamin K deficiency disorders. ? blood anticoagulant effects of its own too strong such as improper use of anticoagulants, presence of anti-fibrinogen circulating anticoagulant or fibrinolytic excessive or accelerated, such as disseminated intravascular coagulation.
(2) acute febrile diseases as flu, influenza, hemorrhagic fever, scarlet fever, malaria, measles and typhoid. More due to high fever, toxic damage angiogenesis, nasal congestion, swelling and dry, resulting in capillary bleeding. Generally less bleeding, occurred in the heat of, and bleeding sites were located in the front of the nasal cavity.
(3) cardiovascular system diseases ? hypertension and arteriosclerosis and atherosclerosis is a major cause of hypertension in the elderly nose bleeding, hardening of the arteries is the pathological basis. Blood pressure, especially in constipation, excessive force or emotional, the nasal blood vessels can rupture, causing bleeding nose. In addition, sneezing, coughing hard, violently nasal breathing or nasal massage, also repeated nose bleeding and uncontrollable factors. ? venous hypertension emphysema, pulmonary heart disease, mitral stenosis, neck or mediastinal lesions and other diseases, can cause high pressure on the vena cava, the patient's nasal cavity and venous engorgement often congestion, When nasopharyngeal intravenous patient coughing or other incentives, blood vessels may rupture, bleeding sites were located at the rear of the nose from the distribution area.
(4) Other systemic diseases pregnancy, early menopause, menopause can cause nose bleeding, may be associated with an increased capillary fragility. Patients with severe liver disease may be due to liver synthesis of clotting factor disorder caused by nasal bleeding. Uremia may also cause nasal bleeding. Nasal bleeding can be one of the early manifestations of rheumatic fever.
Clinical manifestations
Nose bleeding manifestations vary due to different reasons, the majority of unilateral epistaxis, also bilateral; intermittently repeated bleeding, also showed persistent bleeding. Bleeding much different, the light tears in the blood, a few drops or a few milliliters, weight up to tens or even hundreds of milliliters ml or more, leading to hemorrhagic shock. Repeated bleeding can lead to anemia. Few small amount of bleeding can be stopped from retaining or self-oppression.
Most of the bleeding site easy bleeding occurred in the lower part of the front area of ??the nasal septum, and sometimes that small jet or pulsatile arterial bleeding, children, young people nose bleeding occurred in this area. The elderly nose bleeding, often associated with hypertension and atherosclerosis, common in the posterior nasal bleeding site, located near the rear end of the inferior turbinate Wu nose - arterial venous plexus and nasal septum nasopharynx rear. This site bleeding generally more violent and difficult to stop bleeding, bleeding often rapid inflow of the throat, from his mouth. Local disorders caused by nasal bleeding occurred in one side of the nasal cavity, and systemic diseases caused by, may alternately or simultaneously on both sides of the nasal bleeding.
Diagnosis
1. The detailed history and bleeding, bleeding from the nose or confirm adjacent tissue, excluding hemoptysis and vomiting.
2. Determine the bleeding site, combined with front nose, nasal endoscopy and / or CT, MRI examination to determine the emergence site.
3. Blood test for patients suspected of large amount of bleeding and the blood disease is essential. Anticoagulant drugs for patients and suspected coagulation abnormalities, need to check the clotting function.
The estimated blood loss, circulatory system to assess the patient's current condition, with or without hemorrhagic shock, and related departments to be necessary fashion consultation. According to each and bleeding episodes, blood pressure, pulse, and laboratory examination of patients in general to an overall judgment bleeding. When blood loss amounted to 500ml, can be dizziness, thirst, weakness, pale and other symptoms; hemorrhagic capacity 500ml ~ 1000ml may be sweating, blood pressure, pulse rate and weak; if the systolic blood pressure lower than 80mmHg, the prompt blood Capacity has lost about 1/4.
5. The investigation and systemic disease.
Differential Diagnosis
1. hemoptysis
The larynx, trachea, bronchus and lung bleeding, spit up blood through the mouth, common in tuberculosis, bronchiectasis, lung cancer, lung abscess and lung congestion caused by heart disease and so on. According to patients with previous history, signs and laboratory examinations to identify.
2. vomiting
Vomiting is one of the main manifestations of upper gastrointestinal bleeding, when a lot of vomiting, blood gushing from the mouth and nasal cavity, often accompanied by other symptoms of gastrointestinal disease, systemic examination may have positive signs, it can be identified.
Treatment
Nose bleeding is a medical emergency, life-sustaining treatment should first signs, stop bleeding quickly as possible, and gene therapy.
1. General treatment
First, tension, fear of patients and their families comfort, making it calm to avoid patients with high blood pressure caused by psychological factors, so bleeding intensified and timely measure blood pressure, pulse, give fluids if necessary, to maintain stable vital signs. If the patient has shock, you should first first aid for shock. When asked about the history, to ask the following: which side on which side of the nose or nasal bleeding to bleeding, bleeding rate and bleeding, in the past whether the repeated nose bleeding, the bleeding with or without incentives, without other accompanying symptoms.
2. Look for bleeding
Depending on the circumstances, nasal topical and systemic examination. Check the nasal cavity nasal cleared clot, using 1% ephedrine and full contraction and anesthetic tetracaine nasal mucosa, as far as possible to find the bleeding site, in order to accurately stop the bleeding. If the conditions are the best looking in endoscopic bleeding, and implement hemostasis.
3. The method of nasal bleeding
According to the priorities of bleeding, bleeding site, bleeding and etiology, choose different methods to stop bleeding.
(1) means a pressure method can be used in patients with bilateral finger pinching the nose or bleeding nose pressed against the nasal septum side 10 to 15 minutes, can also be rampant finger presses the upper lip area, while cold forehead and neck. This method is suitable for a small amount of bleeding and bleeding in the front part of the nasal cavity of patients, patients with nasal bleeding can occur at home, take this method.
(2) local hemostatic agents suitable for lighter anterior nasal bleeding, this method is simple, less patient pain. For bleeding area, you can apply a piece of cotton soaked in 1% ephedrine, 1 ‰ adrenaline, 3% hydrogen peroxide solution or thrombin, tight stopper nasal few minutes to a few hours, you can stop the bleeding.
(3) burning method commonly used chemicals and physical burn burning (including electric cautery, laser ablation and microwave burning, etc.). Located on the lower front of the nasal septum bleeding, in full contraction and nasal anesthesia after bleeding site clearly visible, available volumes cotton seed dipped in a little 30% to 50% silver nitrate, or 30% trichloroacetic acid burning bleeding, bleeding at the point of pressure in the moment until the local form albuginea.
(4) may be applied before the nose tamponade active when severe nose bleeding or bleeding site was not clear.
Vaseline gauze packing before nose surgery is the traditional methods to stop bleeding, the majority of patients with nasal bleeding after packing to stop bleeding, a small number of patients need repeated row after row packing or further nose tamponade. When vaseline gauze nasal cavity from the top on down layer by layer by folding fill tight, but also by the nasal floor to the top of the nasal packing, have a certain depth and intensity when packing, should the entire pile yarn at the front nostril. After the filling is completed, you should check whether there is still nostril after blood flow into the oropharynx. Subject to the decision of nasal packing was taken out of time, for severe bleeding or blood disease patients should be extended filling time in filling process should be given antibiotics to treat patients, to prevent the concurrent nasal sinus infection.
Vaseline gauze packing the nose before surgery is widely used in the treatment of nasal bleeding, but the larger the suffering of patients, easy to relapse, there are many improved methods, such as: ? bleeding tamponade sleeve coated with oil or ointment finger set into the nasal cavity, and then do the kit gauze packing, this method when filled and removed a sliver less painful. ? hemostasis oppression bladders or balloon with a rubber membrane bleeding into various shapes balloon placed nasal bleeding site, comprising an inflated or filled with water hemostasis. ? other tamponade may use other materials, such as expanded sponge, calcium alginate fibers, etc., suitable for nasal filled the air, a smaller amount of bleeding, hemostatic effect, less painful advantages.
(5) after the nose packing stuffing nose bleeding after surgery is still more than before, back flow into the throat or nasal emission from the opposite side, you should choose after the nostrils tamponade. ? classic nose tamponade after a thin catheter from the lateral nasal bleeding into the oropharyngeal bottom and pull out the mouth, the tip of the catheter in one hand and post-nasal nose embolism after embolization ball sent the ball silk tie into the mouth, gradually pull the other hand makes the nasal catheter embolization after ball into the nose, then nasal packing gauze before, then tie on a silk gauze and secured before the nostril of the patient. Postnasal packing operation is more complex, patients suffering large, generally need to stay in hospital for observation, and given adequate antibiotics to prevent infection, to be checked daily at the soft palate and the front nose redness, swelling, and observe the patient's breathing and eating, general It may pack 3 to 7 days. ? packing method using balloons or bladders with snorkel balloon (Foley tube) as postnasal packing, not only can significantly reduce the suffering of patients, and can greatly reduce the incidence of complications. Most scholars believe that the application of Foley tube so that the nose after embolization is simple and feasible, there are obvious advantages in accident and emergency treatment. Patients can take any position, simple, rapid hemostasis, patients with small physical damage, good treatment, balloon size can be injected into the fluid pressure control, adjustable, small to nasal irritation, light damage, and easy to master the application.
(6) With the advances in endoscopic hemostasis ENT instruments, endoscopic exploration in recent years, the site of bleeding parallel coagulation method has achieved remarkable results, and has been widely used, its efficiency up to 90 % or more, the advantage lies in the nasal cavity ministries, especially the upper part of the front of the nose difficult to observe, rear and nasopharynx and so deep, narrow area under direct vision bleeding, accurate and reliable, with respect to the Vaseline gauze, greatly reducing the damage to the nasal mucosa, little pain. After the bleeding does not need special care, you may need hospitalization, fewer complications. The disadvantage is higher cost.
Rapid development
(7) embolization imaging technology for diagnosis and treatment of severe epistaxis provide assistance, technology, localization of the bleeding site through digital silhouettes angiography (DSA) and the site of vascular embolization. The method is inserted through the femoral artery catheter, selectively placed in the artery, the line imaging and observe the external carotid artery, in determining the bleeding vessel branch, the self-inject embolic agents within the catheter to stop bleeding. Artery embolization can be used: primary nose uncontrollable bleeding, traumatic bleeding nose, internal carotid artery - cavernous fistula, carotid artery rupture and bleeding JNA. The method can directly display the location and cause bleeding, hemostasis quickly, quick, shorten the treatment time. In critical situations large amount of bleeding, digital angiography embolization silhouette is an effective rescue measures. But arterial embolization epistaxis require certain equipment and conditions, technical requirements for high cost patients as well. For allergies, severe atherosclerosis, liver and kidney dysfunction as a taboo, so to strict indications.
(8) Vessel Ligation there is less general application, and more used in severe nose bleeding, a variety of treatment methods described above can not stop bleeding. Before ligation, we should try to determine the source of bleeding right, and then decide which one artery ligation. General upper nasal bleeding artery ligation screening feasible; after nasal bleeding should line the lower part of the maxillary artery or external carotid artery ligation.
(9) nasal surgery nasal mucosa scratches surgery for recurrent nasal bleeding nasal septum caused by a front lower portion of the small blood vessels to dilate. Under local anesthesia, the nasal mucosa scratches to destroy small blood vessels expand network reach to prevent recurrent epistaxis effect. It may also be a laser, radiofrequency and other means to sabotage the expansion of small vascular network. Nasal septum deviation caused by bleeding, nasal surgery feasible.
(10) Other surgery for nasal sinus or nasal bleeding caused by tumors, as the case and nature of the tumor or to stop bleeding, or surgical removal of the tumor, or the use of radiation therapy, or neck artery ligation to stop the bleeding.
4. Systemic treatment
Cause nose bleeding many causes, have different degrees of bleeding. Therapy and treatment of epistaxis can not just nasal bleeding, to take the necessary systemic illness based on basic and special treatment, that bleeding during active treatment of the primary disease.
(1) Looking for bleeding the cause, cause of treatment.
(2) should be performed in patients with bleeding nose bleeding assessment, the patient when treatment is still active bleeding is particularly important.
(3) For elderly patients or patients with bleeding more, pay attention to the situation whether the blood loss anemia, shock and heart damage, etc., and timely manner. Large amount of bleeding in patients, should simultaneously detect blood and preparation of blood, how much rehydration, blood transfusion therapy based on blood loss. Have high blood pressure should be active antihypertensive treatment in elderly patients blood pressure should not drop too quickly, in order to avoid thrombosis.
(4) after the nose nasal packing and packing can cause lower blood oxygen and carbon dioxide partial pressure, so the elderly patients should pay attention to cardiopulmonary function, give oxygen, if necessary, pay attention to the patient's nutrition, and make high-calorie digestible diet.
(5) appropriate use of systemic hemostatic agents, such as thrombin, aminocaproic acid, Etamsylate like.
(6) for the emotional stress of the patient, it may be appropriate to use sedative drugs, psychotherapy for patients relieve stress and anxiety, to prevent re-bleeding, also have a significant role.
Prevention Of Nose Bleeds
Usually should pay attention to the prevention of nose bleeding, measures include:
1. Keep the room quiet, clean, temperature should be appropriate. Indoor keep the air fresh, appropriate window for ventilation, the temperature should be maintained at 18 ? ~ 20 ?. Because the air is too dry can induce nasal bleeding, so the air humidity should be =60%.
2. When the elderly weekday activities move slowly, do not force blow your nose, cough symptomatic.
3. diet to get into some of digestible soft diet, eat more fruits and vegetables, avoid spicy food, and keep stool, constipation may be given laxatives.
The elderly epistaxis patients are associated with high blood pressure, coronary heart disease, bronchitis, regular primary disease prevention must be the appropriate treatment for the cause, especially in patients with hypertension, the blood pressure must be controlled to normal as soon as possible or near-normal levels, observation of changes, and promptly to the hospital.
5. For children nasal bleeding patients should correct the children to dig the nose, rubbing the nose, curious place foreign objects easily lead to bad habits mucosal injury.
