Epistaxis nosebleeds. Bleeding can range from a trickle to a strong flow, and the consequences can be up to a life-threatening hemorrhage range from a small annoyance.
Epistaxis nosebleeds. Bleeding can range from a trickle to a strong flow, and the consequences can be up to a life-threatening hemorrhage range from a small annoyance. Pathophysiology blood comes mainly from a source such as the front locus Kiesselbachii, a septum located in the front-bottom vascular plexus. Less common, but more serious is bleeding in the back of the nose, resulting in the rear or septum above the vomer laterally in the lower or middle turbinate. Bleeding from the back of the nose occur with atherosclerotic vessels or pre-existing bleeding disorder especially after a nasal or sinus surgery in patients. Etiology The most common causes of nosebleeds: local trauma (eg sneezing and nose picking.) Drying of the nasal mucosa There are a number of less common causes (see Table: Causes of nosebleeds). High blood pressure can contribute to a persistent nosebleeds, which has already begun, but is probably not the sole cause. Cause of epistaxis cause Suspicious findings diagnostic approach Frequently, local trauma (. E.g., sneezing, nose-picking, blunt strike) Obviously Usually visibly dry (. In cold weather, for example) Clinical anamnesis Clinical evaluation by drying of the mucous membrane in the examination evaluation Less frequent local infections (eg. B. Vestibulitis, rhinitis) rigidities in the nasal vestibule, often Clinical with local pain and dry mucous clarification Systemic diseases (eg., AIDS, liver disease) Known pre-existing conditions mucosal erosions and hypertrophy Clinical evaluation foreign bodies (especially in children) often recurring nosebleeds with flowing Clinical evaluation Normally atherosclerosis in elderly patients Klinis che clarification Rendu-Osler-Weber syndrome facial telangiectasias, Clinical lips, mouth and nasal mucosa as well as fingers and toes Positive family history clarification tumor (benign or malignant) of the nasopharynx or sinus mass in the nose or nasopharynx bulging of the lateral nasal wall CT septal visible on examination Clinical evaluation Coagulopathy nosebleeds or bleeding at other locations (eg. B. gums) in the history of blood count with platelets, PT / PTT * Regardless of the etiology patients (with increased bleeding tendency z. B. with thrombocytopenia, liver disease, coagulopathies or anticoagulant therapy) frequent nosebleeds. In such patients, the bleeding is often more severe and difficult to treat. Clarification history The history of the disease process should try to determine which side has started to bleed first. Even if the blood flowing quickly over high epistaxis from both nostrils, most patients still know is which side started it, and there should be focusing attention on clinical examination. The duration of the bleeding should be established, as well as all triggers (eg. As sneezing, blowing your nose, picking) and attempts by the patient to stop the bleeding. There may be blood evacuation; blood swallowed is irritant to the stomach and the patients also describe vomiting blood. Important associated symptoms before the outbreak are symptoms of an infection of the upper respiratory tract, feeling of obstruction in the nose and pain in the face or nose. Duration and number of previous episodes of epistaxis and its cessation should be identified. A review of organ systems should ask for excessive bleeding, including easy bleeding, blood or Teerstühlen, coughing up blood, blood in the urine, and excessive bleeding when brushing your teeth, phlebotomy or minor injuries after symptoms. The history should the presence of known bleeding disorders (including family history) and elicit symptoms in connection with defects in platelet or coagulation, in particular cancer, liver cirrhosis, HIV and pregnancy. The drug history should ask specifically for the use of drugs that promote bleeding, including aspirin and other NSAIDs, antiplatelet drugs (eg. As clopidogrel), heparin and Warfarin.Körperliche examination vital signs were clear signs of intravascular volume depletion (tachycardia, hypotension) and high blood pressure are checked. With active bleeding, the treatment takes place simultaneously with the investigation. During active bleeding, an inspection is difficult, therefore, first trying to stop the bleeding, as described below. The nose is then examined using a nasal speculum and a bright headlamp or a head mirror which allows a hand to the suction or for another tool free. An anterior source of bleeding can be seen usually equal in the investigation. If the bleeding source is not clear and there was only one or two minor cases of nosebleeds, further testing is not necessary. But if it is not evident in strong or recurrent nosebleeds, where it came from, fiberoptic endoscopy may be necessary. The general examination should achten.Warnzeichen for signs of bleeding disorders, including petechiae, purpura and telangiectasia perioral and oral mucosa, as well as intranasal masses The following findings are particularly important: symptoms of hypovolemia or hemorrhagic shock using anticoagulants Cutaneous signs of bleeding disorder Bleeding can be by direct pressure or with a vasoconstrictor swab not stop Several recurrences, especially without clear cause interpretation of the findings Many cases have a unique trigger (especially nose blowing or nose picking) as the findings suggest (see table: causes of nosebleeds). tests laboratory tests must not be carried out routinely. However, if symptoms or clinical signs suggestive of other bleeding disorder or with repeated severe nosebleeds a blood count with prothrombin time (prothrombin time, PT) and partial thromboplastin time (PTT) should be levied. On suspicion of foreign body, tumor or sinusitis a CT scan is performed. Treatment of acute treatment depends on whether patients bleed from the front or back of the nose. Hemoglobin level, anemia symptoms and vital signs make the difference whether a blood substitute is needed. All identifiable disorders are treated. Bleeding from the leading nose region nosebleeds can usually be characterized stop that one compresses the nostril 10 minutes, ending the patient (if possible) sits upright. If this maneuver fails, one with a vasoconstrictor (z. B. phenylephrine 0.25%) is inserted and a local anesthetic (eg. As lidocaine 2%) soaked cotton wool pad and the nose again supplied tweaks for 10 min. Thereafter, the source of bleeding can be scabbed by electrocautery or with a silver nitrate Applikatorstift. Most effective is a cauterizing all four directly adjacent to the bleeding vessel quadrant. It must be ensured that the lining is not corrosive to animal. Therefore, silver nitrate is the preferred method. As an alternative, a nasal tampon of absorbent foam offers, which is best additionally coated with bacitracin or mupirocin ointment. all measures prove ineffective, you can get a balloon tamponade the bleeding site try (with a nose of the many balloons commercially available). As another alternative, a packing of 1.3 cm wide (and up to 175 cm long) Vaseline gauze can be pushed forward into the nose. This procedure is painful and usually require the use of analgesics; it should only be used if other methods fail or not available stehen.Blutung from the back of the nose nosebleed from a rear source can be difficult to stop. Often it comes to commercial nose balloons; a Gazepackung can be effective, but can be placed in the back of the nose difficult. Both are extremely unpleasant; therefore recommends an i.v. Sedation and hospitalization. Commercial balloons are to be applied according to the instructions provided with the product. The rear nose pack consists of 10 × 10 cm wide gauze pads that are folded, rolled up, tied with 2-3 yarns (strong suture made of silk) to form a solid bundle and be coated with antibiotic ointment. The ends of a suture thread, are attached to a catheter introduced to the side of the blood flow in the nasal cavity, and discharged through the mouth. After withdrawal of the catheter from the nose, the nose pack is pulled behind the soft palate into place in the nasopharynx, until they completely close it. The suture in the oral cavity is used later to pull out the nose pack. In the area ahead of the pack to the nasal cavity is stuffed sealed with 1.3 cm wide vaseline gauze and the 1st thread front fixed to a gauze roll at the nostrils, to secure the package, which should lie 4-5 days. For prevention of sinusitis or otitis media is about 7-10 days an antibiotic (eg. As amoxicillin / clavulanic acid, 2 times 875 mg / day p.o.) administered. Since a rear nose pack arterial Po2 reduced, O2 is added in addition so long as it is. This procedure is unpleasant and should be avoided if possible. Occasionally, the maxillary artery and its branches must be stopped for hemostasis. The vessel ligature with clips can be performed under endoscopic or microscopic guidance and with access via the maxillary sinus. Alternatively, an angiographic embolization can be performed by an experienced radiologist. This method, when carried out in an appropriate manner, hospitalization verkürzen.Gerinnungsstörungen When Rendu-Osler-Weber syndrome can reduce a split-thickness skin flap surgery (septal Dermatoplastie) the frequency of the epistaxis and compensate for the anemia. In the operating room can be the (Nd: YAG) laser photocoagulation apply. Very effective is also a selective embolization, which is particularly suitable for patients who can not tolerate general anesthesia or in which surgery was unsuccessful. For transnasal endoscopic sinus surgery, the new instruments mean a further improvement. To prevent hepatic encephalopathy, choked with liver disease patients greater amounts of blood should be immediately discharged with enemas or laxatives. The gastrointestinal tract should nonabsorbable with antibiotics (z. B. neomycin, 4 times 1 g / day p.o.) are sterilized to prevent the blood decomposed and ammonia is absorbed. Summary Most cases of epistaxis are located in the front nose area and adjourn at direct printing. A screening (by history and physical examination) on bleeding disorders is significant. Patients should be asked again after the use of aspirin or ibuprofen.