Diagnostic and Diagnostic and emergency care for emergency care for

bleedingbleedingPrepared by:Prepared by:

C.m.s., assistant professor C.m.s., assistant professor of outpatient therapy of outpatient therapy

and emergency medical and emergency medical emergency KSMUemergency KSMU

A.R. AlpyssovaA.R. Alpyssova

The purpose of the lectureThe purpose of the lecture

After completing the lecture, students After completing the lecture, students

should focus on issues of diagnosis andshould focus on issues of diagnosis and

emergency treatment for bleeding in the volume emergency treatment for bleeding in the volume

of the first medical care (doctor'sof the first medical care (doctor's line crews), and line crews), and

depending on the patient - in the amount depending on the patient - in the amount

of specialized careof specialized care (intensive care team, intensive (intensive care team, intensive

care team).care team).

The plan of the lectureThe plan of the lecture

1.1. Hemoptysis: etiology, pathogenesis, classificationHemoptysis: etiology, pathogenesis, classification2.2. Characteristics of hemoptysis in certain diseases, Characteristics of hemoptysis in certain diseases,

differential diagnosis, advices for differential diagnosis, advices for caller, the actions on the calls, treatment of pre-caller, the actions on the calls, treatment of pre-hospitalhospital

3.3. Gastrointestinal bleeding: definition, Gastrointestinal bleeding: definition, causes, classification, clinical picturecauses, classification, clinical picture

4.4. Possible complications of gastrointestinal Possible complications of gastrointestinal bleeding, the action on the calls, bleeding, the action on the calls, prehospital treatmentprehospital treatment

5.5. Epistaxis: etiology, pathogenesis, classification, Epistaxis: etiology, pathogenesis, classification, clinical pictureclinical picture

6.6. Epistaxis: etiology, pathogenesis, classification, Epistaxis: etiology, pathogenesis, classification, clinical picture. Action on the call in epistaxis, pre-clinical picture. Action on the call in epistaxis, pre-hospital treatment, indications hospital treatment, indications for hospitalization, common errorsfor hospitalization, common errors

HEMOPTYSISHEMOPTYSIS

HemoptysisHemoptysis -  the appearance of the sputum admixture of  -  the appearance of the sputum admixture of blood.blood.

ETIOLOGY AND PATHOGENESISETIOLOGY AND PATHOGENESIS Infections:Infections: - Bronchitis (acute, but in most cases, chronic);- Bronchitis (acute, but in most cases, chronic);

- Pneumonia;- Pneumonia;- Abscess;- Abscess;- Tuberculosis;- Tuberculosis;- Bronchiectasis.- Bronchiectasis.• • Tumors:Tumors:

- Cancer;- Cancer;- Carcinoid.- Carcinoid.

Diseases of the cardiovascular system:Diseases of the cardiovascular system:- Pulmonary - Pulmonary - Pulmonary embolism;- Pulmonary embolism;

- Pulmonary infarction;- Pulmonary infarction;- Mitral stenosis and other valvular heart - Mitral stenosis and other valvular heart disease, causing increased pressure in the pulmonary disease, causing increased pressure in the pulmonary artery;artery;- Left ventricular failure - pulmonary edema;- Left ventricular failure - pulmonary edema;- Malformations of the pulmonary arteries and veins;- Malformations of the pulmonary arteries and veins;- Aortic aneurysm (blood oozing into the lung tissue).- Aortic aneurysm (blood oozing into the lung tissue).

Injuries:Injuries: - Damage to the chest;- Damage to the chest;

- Postoperative period;- Postoperative period; Other causes:Other causes: - Diseases of the blood, coagulation disorders;- Diseases of the blood, coagulation disorders;

- Therapy and anti-coagulants;- Therapy and anti-coagulants;- Foreign body;- Foreign body;- Vasculitis.- Vasculitis.

According to the mechanism of developmentAccording to the mechanism of developmentof hemoptysis may be due to:of hemoptysis may be due to:

- Mechanical trauma or injury of vessels (foreign - Mechanical trauma or injury of vessels (foreign body, chest injury, biopsies and body, chest injury, biopsies and other traumatic effects);other traumatic effects);- Pathological process with the formation of a - Pathological process with the formation of a defect of the vascular wall (erosive bleeding tumor, a defect of the vascular wall (erosive bleeding tumor, a cavity, bronchiectasis, and other pathological cavity, bronchiectasis, and other pathological processes);processes);- Violation of the permeability of the vascular - Violation of the permeability of the vascular wall (acute infectious diseases and other causes).wall (acute infectious diseases and other causes).

CLASSIFICATIONCLASSIFICATION

According to the degree of blood loss:According to the degree of blood loss:

lung (favorable prognosis): streaks of blood or a lung (favorable prognosis): streaks of blood or a

uniform admixture of bright red color in the uniform admixture of bright red color in the

sputum;sputum;

severe (life threatening): massive severe (life threatening): massive

bleeding (coughing up large amounts of blood in bleeding (coughing up large amounts of blood in

each spitting phlegm or 1000 ml for 24 h).each spitting phlegm or 1000 ml for 24 h).

Characteristics of hemoptysis in certain diseasesCharacteristics of hemoptysis in certain diseases

Acute bronchitis Muco-purulent sputum withblood-streaked

Pneumonia Rusty sputum; acute illness with fever and shortness of breath; inflammatory lesion in the lung

Abscess lungs Purulent sputum with blood streaks, fever, chest pain with pleural character

Tuberculosis Purulent sputum with blood streaks, lowering the mass

Tuberculoma Spherical infiltrate on the radiograph of the chest, a history of tuberculosis

Bronchiectasis Copious purulent sputum, hemoptysis in previous episodes for months or years

Characteristics of hemoptysis in certain diseasesCharacteristics of hemoptysis in certain diseases

Bronchus cancer Prolonged release ofsputum with blood streaks, weight loss

Adenoma of the bronchus

Recurrent hemoptysis in apparently healthy people

Pulmonary infarction Blood clots are not mixed with phlegm; chest pain with pleural character and shortness of breath; risk factors for deep vein thrombosis of lower extremities, pelvic veins.

Pulmonary edema Frothy sputum, blood stained (pink), marked dyspnea, concomitant heart disease

Malformations of the vessels of the lungs

Recurrent hemoptysis, syndrome of Osler-Weber -Rendu with multiple telangiectasia

Characteristics of hemoptysis in certain Characteristics of hemoptysis in certain diseasesdiseasesContusion of lungs Prior injury of the chest

Bleeding diathesis Hemoptysis after persistent cough, bleeding from various organs

Pulmonary vasculitis Wegener's granulomatosis (involving upper and lower respiratory tract, antinuclear antibodies), Goodpasture's syndrome (involvement of lung and kidney, antibodies to glomerular basement membrane)

Congenital heart disease Cyanosis, a symptom of "drumsticks"

Other causes of pulmonary hypertension

Mitral stenosis, primary pulmonary hypertension

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS When hemoptysis (Kr.) observes a bright red color of When hemoptysis (Kr.) observes a bright red color of

separate; Hemoptysis is usually accompanied separate; Hemoptysis is usually accompanied by cough, sputum alkaline reaction.by cough, sputum alkaline reaction.

Vomiting of blood - brown, blood inVomiting of blood - brown, blood in the form of the form of clots, mixed with food mass, the reaction clots, mixed with food mass, the reaction of acidic secretions.of acidic secretions.

Bleeding from the gums or throat may be taken by mistakeBleeding from the gums or throat may be taken by mistakefor hemoptysisfor hemoptysis

ADVICES FOR CALLERADVICES FOR CALLER Help the patient to breathe freely (unfasten the clothing, Help the patient to breathe freely (unfasten the clothing,

remove dentures).remove dentures). Lay the patient on his back, lift the head end.Lay the patient on his back, lift the head end. At massive hemoptysis or unconsciousness, recovery At massive hemoptysis or unconsciousness, recovery

positionposition Do not allow the patient to get up (total immobilization).Do not allow the patient to get up (total immobilization). Try to calm the patient.Try to calm the patient. Do not let the patient eat or drink.Do not let the patient eat or drink. Find those drugs that the patient takes, and show them Find those drugs that the patient takes, and show them

to the doctor or the assistant emergency medical services.to the doctor or the assistant emergency medical services. Do not leave patient unattended.Do not leave patient unattended. A. Position: with a raised head end.A. Position: with a raised head end. B. Recovery position.B. Recovery position.

ACTIONS IN CHALLENGEACTIONS IN CHALLENGE OBLIGATORY QUESTIONSOBLIGATORY QUESTIONS When started coughing up blood? How many times was it?When started coughing up blood? How many times was it? Description of the character of sputum (veins, Description of the character of sputum (veins,

clots, unmodified red bloodclots, unmodified red blood Under what circumstances arose hemoptysis (at Under what circumstances arose hemoptysis (at

rest, during exercise, in a fit ofrest, during exercise, in a fit of coughing, chest trauma and other conditions)?coughing, chest trauma and other conditions)?

Accompanied by a cough?Accompanied by a cough? Is there any pain in your chest or? Check if Is there any pain in your chest or? Check if

any character (like angina withany character (like angina with retrosternal localizationretrosternal localization ororaggravated by breathing and plevritic coughing?aggravated by breathing and plevritic coughing?

What are the common symptoms (fatigue, tachycardia, What are the common symptoms (fatigue, tachycardia, dyspnea, fever, etc.)?dyspnea, fever, etc.)?

For the first time or again?For the first time or again? What caused the previous episodes,What caused the previous episodes,

with what stoped?with what stoped? What diseases are present in the patient (cardiac, What diseases are present in the patient (cardiac,

pulmonary, cancer, tuberculosis, etc.)?pulmonary, cancer, tuberculosis, etc.)? Was not the recent operations on the organs of the Was not the recent operations on the organs of the

chest, biopsy, etc.?chest, biopsy, etc.? Does the patient smoke? If yes, how many cigarettes per Does the patient smoke? If yes, how many cigarettes per

day and for how long?day and for how long?

INSPECTION AND PHYSICAL EXAMINATIONINSPECTION AND PHYSICAL EXAMINATION Assessment of general condition and vital Assessment of general condition and vital

signs: consciousness, breathing and circulation.signs: consciousness, breathing and circulation. The extent of bleeding.The extent of bleeding. Visual inspection of the skin and visible mucous, Visual inspection of the skin and visible mucous,

including the mouth, nose and throat.including the mouth, nose and throat. Assessment of the character of sputum.Assessment of the character of sputum. The study of pulse, measurement of heart rate,The study of pulse, measurement of heart rate,

measurementmeasurement of blood pressure.of blood pressure. Auscultation of the heart and lungs.Auscultation of the heart and lungs. Physical examination reveals a possible cause Physical examination reveals a possible cause

of hemoptysis, but could not reveal significant of hemoptysis, but could not reveal significant deviations from the norm.deviations from the norm.

TreatmentTreatment At loss of consciousness, cardiac At loss of consciousness, cardiac

arrest and / or respiratory conduct cardiopulmonary arrest and / or respiratory conduct cardiopulmonary resuscitation.resuscitation.

In heavy (massive) hemorrhage:In heavy (massive) hemorrhage: put the patient with lowered head end;put the patient with lowered head end; ensure sanitation of the respiratory tract;ensure sanitation of the respiratory tract; ensure supply of O2 at high speed (6-10 l / min);ensure supply of O2 at high speed (6-10 l / min); provide venous access (if possible several) provide venous access (if possible several)

and transfusion of fluids (1000-3000mL, and transfusion of fluids (1000-3000mL, depending on the clinical picture): 0.9% solution depending on the clinical picture): 0.9% solution of NaCl, 5% dextrose;of NaCl, 5% dextrose;

enter intravenously aminocaproic acid 5% - 100 ml (5 enter intravenously aminocaproic acid 5% - 100 ml (5 g), but its effectiveness in profuse bleeding is low;g), but its effectiveness in profuse bleeding is low;

provide emergency hospitalization of patients in provide emergency hospitalization of patients in hospitals with thoracic surgery department.hospitals with thoracic surgery department.

In mild hemorrhage spend symptomatic therapyIn mild hemorrhage spend symptomatic therapy Control of hemodynamics and saturation of blood Control of hemodynamics and saturation of blood

with oxygen to maintain vital functions (in with oxygen to maintain vital functions (in accordance with common resuscitation principles).accordance with common resuscitation principles).

INDICATION FOR HOSPITALIZATIONINDICATION FOR HOSPITALIZATION Massive hemorrhage - indication Massive hemorrhage - indication

for emergency admissions to hospital with a for emergency admissions to hospital with a department of thoracic surgery.department of thoracic surgery.

Transporting a patient lying on a stretcher with a Transporting a patient lying on a stretcher with a raised foot end.raised foot end.

When hemoptysis in all patients hospitalization is When hemoptysis in all patients hospitalization is shown to determine the cause and / or shown to determine the cause and / or destination therapy. The exceptions destination therapy. The exceptions are patients with a known diagnosis (eg are patients with a known diagnosis (eg cancer bronchus, cancer bronchus, bronchiectasis), stopped bleeding and stable bronchiectasis), stopped bleeding and stable state.state.

COMMON ERRORSCOMMON ERRORS Application of hemostatic means with Application of hemostatic means with

mild hemoptysis.mild hemoptysis.

GATROINTESTINAL BLEEDINGGATROINTESTINAL BLEEDING

Bleeding -Bleeding - going out of bloodgoing out of blood of the bloodstream. of the bloodstream. Massive bleeding from the gastrointestinal tract is Massive bleeding from the gastrointestinal tract is often the cause of life-threateningoften the cause of life-threatening of hemorrhagic of hemorrhagic shock.shock.

ETIOLOGY AND PATHOGENESISETIOLOGY AND PATHOGENESISMost often the bleeding is due to:Most often the bleeding is due to:

pathological process of the formation of a defect of pathological process of the formation of a defect of the vascular wall (erosive bleeding from acute or the vascular wall (erosive bleeding from acute or chronic ulcers, decaying tumor);chronic ulcers, decaying tumor);

violation of the permeability of the vascular wall violation of the permeability of the vascular wall (vitamin deficiency, an acute infectious disease, (vitamin deficiency, an acute infectious disease, anaphylaxis, sepsis, intoxication);anaphylaxis, sepsis, intoxication);

Emergency state in diseases of the abdominal Emergency state in diseases of the abdominal cavity:cavity:

bleeding from varices of the esophagus bleeding from varices of the esophagus and stomach in liver cirrhosis;and stomach in liver cirrhosis;

bleeding from esophageal tears, and bleeding from esophageal tears, and stomach (Mallory-Weiss syndrome).stomach (Mallory-Weiss syndrome).

Allocate the bleeding:Allocate the bleeding:- Of upper gastrointestinal bleeding, - Of upper gastrointestinal bleeding, when the when the

source is located in the esophagus, source is located in the esophagus, stomach, duodenum (proximal to stomach, duodenum (proximal to the ligament Treyttsa)the ligament Treyttsa)

- Lower GI- Lower GI - a source of jejunum and ileum, to the  - a source of jejunum and ileum, to the colon.colon.

The causes of gastrointestinal bleeding:The causes of gastrointestinal bleeding: upper gastrointestinal:upper gastrointestinal: duodenal  duodenal

ulcer and / or stomach, varicose veins of the ulcer and / or stomach, varicose veins of the esophagus, erosive and ulcerative lesions of the esophagus, erosive and ulcerative lesions of the mucosa (stress, medications, azotemic, mucosa (stress, medications, azotemic, etc.), Mallory-Weiss syndrome, tumors of the etc.), Mallory-Weiss syndrome, tumors of the esophagus, stomach and duodenal esophagus, stomach and duodenal ulcers, angiomas .ulcers, angiomas .

of lower GI:of lower GI: diverticulitis or  diverticulitis or mekkelev’s diverticular , tumors and polyps of the mekkelev’s diverticular , tumors and polyps of the colon, angiodisplaziya, ulcerative colitis and Crohn's colon, angiodisplaziya, ulcerative colitis and Crohn's disease, hemorrhoids, infectious diseases.disease, hemorrhoids, infectious diseases.

CLASSIFICATIONCLASSIFICATION Gastrointestinal bleeding classify due to, Gastrointestinal bleeding classify due to, localize the localize the

source of bleeding, the nature(acute, profuse, source of bleeding, the nature(acute, profuse, recurrent and repetitive), and depending on the recurrent and repetitive), and depending on the degree of blood loss.degree of blood loss.

Mild (Grade I). Satisfactory Mild (Grade I). Satisfactory condition. Disposable vomiting or single formed stoolscondition. Disposable vomiting or single formed stools with with black color. The heart rate of 80-100 per minute, systolic black color. The heart rate of 80-100 per minute, systolic blood pressure> 110 mm Hg,blood pressure> 110 mm Hg, urine output> 2 L / day.urine output> 2 L / day.

Moderate severity (grade II). The patient's condition to Moderate severity (grade II). The patient's condition to moderate severity.moderate severity. Repeated vomiting of Repeated vomiting of blood or melena. The heart rate of 100-110 per minute,blood or melena. The heart rate of 100-110 per minute, systolic blood pressure 100-120 mm Hg, urine output <2 systolic blood pressure 100-120 mm Hg, urine output <2 L / day.L / day.

Severe (Grade III). The condition was Severe (Grade III). The condition was grave, disturbed consciousness up to coma.grave, disturbed consciousness up to coma. Repeated vomiting little-changes in the blood, Repeated vomiting little-changes in the blood, loose stools or tarry stools in an "raspberry jelly." Heart loose stools or tarry stools in an "raspberry jelly." Heart rate> 120 per minute, systolic blood pressure <90 mm Hg. rate> 120 per minute, systolic blood pressure <90 mm Hg. oliguria, metabolic acidosis.oliguria, metabolic acidosis.

CLINICAL PICTURECLINICAL PICTURE Allocate Allocate latent periodlatent period, when there are no obvious , when there are no obvious

signs of gastrointestinal bleeding(systemic signs of gastrointestinal bleeding(systemic symptoms) and the period of overt symptoms) and the period of overt signs (vomiting, melena).signs (vomiting, melena).

If internal bleedingIf internal bleeding blood may pour out blood may pour outunchanged (ischemic colitis, colon tumors, decay and unchanged (ischemic colitis, colon tumors, decay and rectum, acute hemorrhoids), as rectum, acute hemorrhoids), as well as vomiting, bloody mucus, meleny.well as vomiting, bloody mucus, meleny.

Vomiting:Vomiting: red blood syndrome (Mzllori- red blood syndrome (Mzllori-Weiss, cancer of the esophagus or cardia);Weiss, cancer of the esophagus or cardia);

dark blood (bleeding from esophageal varices, dark blood (bleeding from esophageal varices, stomach in portal hypertension);stomach in portal hypertension);

the type of "coffee ground" (bleeding from chronic or the type of "coffee ground" (bleeding from chronic or acute gastric ulcer andacute gastric ulcer and duodenal ulcer).duodenal ulcer).

Bloody mucusBloody mucus (dysentery,  (dysentery, ulcerative colitis, rectal fissure).ulcerative colitis, rectal fissure).

melena melena (black stools due to the transformation of (black stools due to the transformation of hemoglobin into hemosiderin) -for hemoglobin into hemosiderin) -for bleeding from upper gastrointestinalbleeding from upper gastrointestinal

In severe hemorrhage observed:In severe hemorrhage observed: pale skin and conjunctiva;pale skin and conjunctiva; frequent and soft pulse;frequent and soft pulse; weakness;weakness; dizziness when standing up or loss of consciousness dizziness when standing up or loss of consciousness

(collapse);(collapse); Reduction ofReduction of blood pressure blood pressure High-risk group is distinguished by several features:High-risk group is distinguished by several features: Age older than 60 years.Age older than 60 years. Shock - systolic BP <100 mm Hg in patients 60 Shock - systolic BP <100 mm Hg in patients 60

years and <120 mm Hg in patients over 60 years of age years and <120 mm Hg in patients over 60 years of age (young people more easily transferred to massive blood (young people more easily transferred to massive blood loss). If difficulty in qualifying status of patients should be loss). If difficulty in qualifying status of patients should be evaluated fall in blood pressure and / or the appearance of evaluated fall in blood pressure and / or the appearance of tachycardia with a change in body position.tachycardia with a change in body position.

Marked bradycardia or heart rate> 120 per minute.Marked bradycardia or heart rate> 120 per minute. Chronic liver disease.Chronic liver disease. Other chronic diseases (eg, heart, bronchial and Other chronic diseases (eg, heart, bronchial and

lung spasms, kidney)lung spasms, kidney) Hemorrhagic diathesis.Hemorrhagic diathesis. Impaired consciousnessImpaired consciousness Long-term treatment with anticoagulants, antiplatelet Long-term treatment with anticoagulants, antiplatelet

agents and heparin.agents and heparin. Long-term therapy of UAIM (Unstereoid anti inflammatory Long-term therapy of UAIM (Unstereoid anti inflammatory

means)means)

POSSIBLE COMPLICATIONSPOSSIBLE COMPLICATIONS The most serious complication - hemorrhagic The most serious complication - hemorrhagic

shock.shock. Bleeding can lead to a decrease or disappearance Bleeding can lead to a decrease or disappearance

of signs of main disease that led to this of signs of main disease that led to this complication, and provoke its aggravation. In complication, and provoke its aggravation. In patients with liver disease bleeding can cause the patients with liver disease bleeding can cause the development of liver failure development of liver failure and encephalopathy; a combination of disease, and encephalopathy; a combination of disease, which led to bleeding from coronary artery which led to bleeding from coronary artery disease may develop angina or myocardial disease may develop angina or myocardial infarction, exacerbation of infarction, exacerbation of hypertension, diabetes, renal failure, etc.hypertension, diabetes, renal failure, etc.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS Pulmonary hemorrhage, which is accompanied Pulmonary hemorrhage, which is accompanied

by cough and hemoptysis (erosionof vessels in by cough and hemoptysis (erosionof vessels in patients with broektazes, pneumosclerosis, as well as in patients with broektazes, pneumosclerosis, as well as in tumors oftumors of the larynx and bronchi, tuberculosis).the larynx and bronchi, tuberculosis).

Often causesOften causes in bleeding, hypotension in bleeding, hypotension with retrosternal pain attack and leads to with retrosternal pain attack and leads to secondary ECG signs of acute myocardial ischemia. This secondary ECG signs of acute myocardial ischemia. This combination of no obvious signs of bleeding contributes combination of no obvious signs of bleeding contributes to an erroneous diagnosis of coronary artery disease to an erroneous diagnosis of coronary artery disease and cardiogenic shock and hospitalization in the coronary and cardiogenic shock and hospitalization in the coronary carecare department.department.

Keep in mind that one reason Keep in mind that one reason for vomiting blood, may be swallowing blood epistaxis.for vomiting blood, may be swallowing blood epistaxis.

ADVICES FOR CALLERADVICES FOR CALLER Lay the patient on his back and lift your legs above your Lay the patient on his back and lift your legs above your

head at 20-30 cmhead at 20-30 cm Do not let the patient eat or drink.Do not let the patient eat or drink. Find the medication that the patient takes, and show them Find the medication that the patient takes, and show them

to the doctor or nurse of UMC (Urgent medical care).to the doctor or nurse of UMC (Urgent medical care). Do not leave patient unattended.Do not leave patient unattended. Cold on the stomach.Cold on the stomach.

ACTION ON CHALLENGEACTION ON CHALLENGE When started bleeding? How much time continued? When started bleeding? How much time continued? Was the use of alcohol before?Was the use of alcohol before? Do you suffer from a peptic ulcer? Bothered whether Do you suffer from a peptic ulcer? Bothered whether

earlier epigastric pain earlier epigastric pain (suspected to aggravate (suspected to aggravate peptic ulcer disease)?peptic ulcer disease)?

Are there any difficulty in swallowing food Are there any difficulty in swallowing food (oesophageal suspected pathology)?(oesophageal suspected pathology)?

Were there other forms of bleeding? Has the Were there other forms of bleeding? Has the hematologist hematologist (evidence of hematological (evidence of hematological disease)!disease)!

What medicine to take What medicine to take (many drugs can cause (many drugs can cause mucosal damage or worsening of peptic ulcer mucosal damage or worsening of peptic ulcer disease)!disease)!

Has change the color and character of the stool; Has change the color and character of the stool; whether there is an admixture of blood in it?whether there is an admixture of blood in it?

Does the patient lose consciousness?Does the patient lose consciousness?

INSPECTION AND PHYSICAL EXAMINATIONINSPECTION AND PHYSICAL EXAMINATIONAssessment of general condition and vital signs: consciousness, Assessment of general condition and vital signs: consciousness,

breathing and circulation.breathing and circulation. Visual assessment: pale skin and mucous membranes, signs Visual assessment: pale skin and mucous membranes, signs

of liver disease (telangiectasia, increased subcutaneous veins of liver disease (telangiectasia, increased subcutaneous veins of abdomen, jaundice, ascites), rash (manifestations of of abdomen, jaundice, ascites), rash (manifestations of systemic disease), cachexia (cancer diseases).systemic disease), cachexia (cancer diseases).

Investigation of PS, measuring heart rate, blood pressure Investigation of PS, measuring heart rate, blood pressure measurement (tachycardia, hypotension).measurement (tachycardia, hypotension).

Abdomen soft, evenly involved in the act of breathing, painful Abdomen soft, evenly involved in the act of breathing, painful or painless enough.or painless enough.

Rectal finger examination: detection meleny, hemorrhoids, Rectal finger examination: detection meleny, hemorrhoids, the definition of overhanging anterior wall of the rectum or the definition of overhanging anterior wall of the rectum or bulging posterior vaginal fornix (internal abdominal bulging posterior vaginal fornix (internal abdominal bleeding).bleeding).

The presence of associated symptoms:The presence of associated symptoms: - Melena occurs when entering into the lumen of the stomach - Melena occurs when entering into the lumen of the stomach

at least 200ml of blood. Duration meleny not always at least 200ml of blood. Duration meleny not always indicative of ongoing bleeding, and corresponds to the indicative of ongoing bleeding, and corresponds to the promotion of blood through the intestines (melena may occur promotion of blood through the intestines (melena may occur after 4-6 start after bleeding)after 4-6 start after bleeding)

Blood in the stool.Blood in the stool. Vomiting (red blood, dark blood, coffee grounds).Vomiting (red blood, dark blood, coffee grounds).

Indications for hospitalization. Indications for hospitalization. If the obvious If the obvious symptoms or suspicion to continued or held symptoms or suspicion to continued or held bleeding of patient should extremely hospitalize. bleeding of patient should extremely hospitalize. Transportation in a prone position on a stretcher Transportation in a prone position on a stretcher with a raised head end.with a raised head end.

Common errors. Common errors. Delayed hospitalization in an Delayed hospitalization in an apparent stop bleeding, which can recur at any apparent stop bleeding, which can recur at any time.time.

TREATMENT ON PREHOSPITAL STAGETREATMENT ON PREHOSPITAL STAGEThe main objective of the UMC at FCC - emergency The main objective of the UMC at FCC - emergency

hospitalization of the patient in a hospital surgical hospitalization of the patient in a hospital surgical department. Should monitor and control blood pressure and department. Should monitor and control blood pressure and

heart rate to maintain vital functions in accordance with heart rate to maintain vital functions in accordance with general principles of resuscitation).general principles of resuscitation).

With signs of hemorrhagic shock (chills, cold sweat, With signs of hemorrhagic shock (chills, cold sweat, decrease venous filling, increasing tachycardia (heart rate> decrease venous filling, increasing tachycardia (heart rate> 100 min) and hypotension (blood pressure <100 mm Hg) to 100 min) and hypotension (blood pressure <100 mm Hg) to start a transfusion fluid intravenously: 400 ml hydroxyethyl start a transfusion fluid intravenously: 400 ml hydroxyethyl starch, glucose 5% - 400 ml sodium Chloride 0.9% - 400 ml.starch, glucose 5% - 400 ml sodium Chloride 0.9% - 400 ml.

If the patient has no signs of hemorrhagic shock, we should If the patient has no signs of hemorrhagic shock, we should not rush to infusion therapy.not rush to infusion therapy.

When bleeding from the upper digestive tract:When bleeding from the upper digestive tract: intravenously slowly over 2 minutes famotidine 20 mg (1 intravenously slowly over 2 minutes famotidine 20 mg (1

vial pre-diluted in 5-10 ml of 0.9% solution of NaCl), vial pre-diluted in 5-10 ml of 0.9% solution of NaCl), intravenous drip ( subcutaneous under skin injection intravenous drip ( subcutaneous under skin injection administration) of 0.1 mg octreotide (analogue administration) of 0.1 mg octreotide (analogue somatostagina).somatostagina).

When bleeding on the background of activation of When bleeding on the background of activation of fibrinolysis (parenchymal hemorrhage, or prolonged loss of fibrinolysis (parenchymal hemorrhage, or prolonged loss of blood) intravenous drip ε-aminocaproic acid, 5% - 100 ml (5 blood) intravenous drip ε-aminocaproic acid, 5% - 100 ml (5 g), however, its effectiveness in profuse bleeding is low.g), however, its effectiveness in profuse bleeding is low.

NOSEBLEEDSNOSEBLEEDS

Nasal bleeding (NB) - clinical symptom of a Nasal bleeding (NB) - clinical symptom of a general or local pathological process - shows no general or local pathological process - shows no separation of blood frothing from the nostrils or separation of blood frothing from the nostrils or drip it on the back of the throat. Patients with drip it on the back of the throat. Patients with bleeding from the nose to 3% of total admissions bleeding from the nose to 3% of total admissions in the LOR department.in the LOR department.

Etiology and pathogenesisEtiology and pathogenesis Causes of NB Causes of NB is divided into local and general (systemic).is divided into local and general (systemic).

GeneralGeneral::- Systemic diseases (atherosclerosis, hypertension, liver - Systemic diseases (atherosclerosis, hypertension, liver

zabolyvaniya)zabolyvaniya)- Infectious diseases (influenza, diphtheria, scarlet fever, - Infectious diseases (influenza, diphtheria, scarlet fever, measles, typhoid fever)measles, typhoid fever)- Hypovitaminosis- Hypovitaminosis- Intoxication (heavy metals, chromium, mercury, - Intoxication (heavy metals, chromium, mercury, phosphorus)phosphorus)- Drugs (anticoagulants, anti vospalitelnh insufficiency of - Drugs (anticoagulants, anti vospalitelnh insufficiency of funds, cytostatics)funds, cytostatics)- Diseases of the blood (leukemia, anemia, - Diseases of the blood (leukemia, anemia, agranulocytosis, multiple myeloma, hemophilia, agranulocytosis, multiple myeloma, hemophilia, idiopatich. Trombotsitopenich. Purpura)idiopatich. Trombotsitopenich. Purpura)- Hereditary haemorrhagic telangiectasia (Osler-Rendu - Hereditary haemorrhagic telangiectasia (Osler-Rendu disease-Weber)disease-Weber)- Endocrine disorders (pregnancy, dysmenorrhea)- Endocrine disorders (pregnancy, dysmenorrhea)- Sepsis- Sepsis- A sharp drop in atmospheric pressure- A sharp drop in atmospheric pressure- General hyperthermia- General hyperthermia- The physical strain- The physical strain- Radiation sickness- Radiation sickness

Pathogenesis. Pathogenesis. Is a violation of the integrity of Is a violation of the integrity of the vascular wall: arterial damage (diseases of the vascular wall: arterial damage (diseases of the cardiovascular system) or venous (in the cardiovascular system) or venous (in inflammatory diseases of the nose and paranasal inflammatory diseases of the nose and paranasal sinuses) vessels.sinuses) vessels.

CLASSIFICATIONCLASSIFICATION As a preferred allocation of blood from the As a preferred allocation of blood from the

anterior or posterior anterior or posterior nasal epistaxis is divided nasal epistaxis is divided into front and rear.into front and rear.

By the nature of the damaged vessel nosebleeds By the nature of the damaged vessel nosebleeds may be may be capillary, arterial and venous.capillary, arterial and venous.

By the nature of the damaged vessel nosebleeds By the nature of the damaged vessel nosebleeds may be capillary, arterial and venous.may be capillary, arterial and venous.On the main causal factor is isolated primary (due On the main causal factor is isolated primary (due to local factors) and to local factors) and secondarysecondary (if common (if common diseases) diseases) nosebleeds.nosebleeds.

Pathogenetic classification (I.A. Kurilin).Pathogenetic classification (I.A. Kurilin). I. Due to vascular disease of the nasal cavity: I. Due to vascular disease of the nasal cavity: • •

injury; • degenerative processes of the mucous injury; • degenerative processes of the mucous membrane of the nasal cavity; • curvature of the nasal membrane of the nasal cavity; • curvature of the nasal septum; • development of vascular abnormalities of the septum; • development of vascular abnormalities of the nasal cavity; • neoplasms of the nose and paranasal nasal cavity; • neoplasms of the nose and paranasal sinuses (bleeding polypus of the nasal septum, angioma, sinuses (bleeding polypus of the nasal septum, angioma, angiofibroma).angiofibroma).

II. As a manifestation of violations II. As a manifestation of violations hemocoagulational properties: hemocoagulational properties: • lowering the activity • lowering the activity of plasma clotting factors; • reduction of platelet activity of plasma clotting factors; • reduction of platelet activity of clotting factors; • increased activity of anticoagulation; of clotting factors; • increased activity of anticoagulation; • giperfibrinoliticheskie state.• giperfibrinoliticheskie state.

III. Caused by the combined effect of vascular III. Caused by the combined effect of vascular pathology of the nasal cavity and pathology of the nasal cavity and hemocoagulation: hemocoagulation: • degenerative lesions of • degenerative lesions of endothelium in atherosclerosis and hypertension; • endothelium in atherosclerosis and hypertension; • hemorrhagic diathesis, chronic liver disease (hepatitis, hemorrhagic diathesis, chronic liver disease (hepatitis, cirrhosis); • chronic inflammatory disease of the nasal cirrhosis); • chronic inflammatory disease of the nasal cavity and paranasal sinuses (Purulent and allergies); • cavity and paranasal sinuses (Purulent and allergies); • diseases of the blood.diseases of the blood.

THE CLINICAL PICTURETHE CLINICAL PICTUREThe main symptom - not the foaming blood outflow The main symptom - not the foaming blood outflow

or jet drops from the nostrils or the drainage of or jet drops from the nostrils or the drainage of the posterior pharyngeal wall.the posterior pharyngeal wall.

Additional features: Additional features: • bloody vomiting (occurs • bloody vomiting (occurs by ingestion of blood and hit her in the stomach); by ingestion of blood and hit her in the stomach); • melena (black stools) during prolonged • melena (black stools) during prolonged recurrent epistaxis; • coughing blood when hit in recurrent epistaxis; • coughing blood when hit in the throat and lower airways; • pale skin; • cold the throat and lower airways; • pale skin; • cold sweat; • frequent and soft pulse; • changes in sweat; • frequent and soft pulse; • changes in blood pressure; • dizziness; • ringing in the ears blood pressure; • dizziness; • ringing in the ears and head; • disturbance of consciousness.and head; • disturbance of consciousness.

Possible complicationsPossible complications Hemorrhagic shock.Hemorrhagic shock. Syncope.Syncope. Hemorrhagic anemia.Hemorrhagic anemia. Exacerbation of chronic diseases with the Exacerbation of chronic diseases with the

development of liver failure (in liver disease), development of liver failure (in liver disease), angina attack or myocardial infarction (in angina attack or myocardial infarction (in coronary heart disease), etc.coronary heart disease), etc.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISBleeding from the lower respiratory tract: Bleeding from the lower respiratory tract: scarlet blood, scarlet blood,

bubble, accompanied by cough and hemoptysis.bubble, accompanied by cough and hemoptysis.Bleeding from the upper gastrointestinal tract Bleeding from the upper gastrointestinal tract in contact in contact

with blood during vomiting in the nasal cavity: a typical with blood during vomiting in the nasal cavity: a typical anamnesis and examination data.anamnesis and examination data.

ADVICES TO CALLERADVICES TO CALLER Give the patient a comfortable position (sitting with his head Give the patient a comfortable position (sitting with his head

slightly tilted forward), unbutton the collar of the patient, slightly tilted forward), unbutton the collar of the patient, relax zone.relax zone.

In the face of the patient to place the capacity to collect In the face of the patient to place the capacity to collect bleeding.bleeding.

On the threshold of a nose bleed on the side to enter the On the threshold of a nose bleed on the side to enter the tampon [can be soaked in a 3% solution of hydrogen tampon [can be soaked in a 3% solution of hydrogen peroxide or 0.1% p-rum epinephrine (INN: epinephrine)] and peroxide or 0.1% p-rum epinephrine (INN: epinephrine)] and squeeze it through the septum of the nose to the wing for squeeze it through the septum of the nose to the wing for 10-15 minutes.10-15 minutes.

The patient should be deep, slow breathing through the The patient should be deep, slow breathing through the mouth, spitting out blood into the vessel, flow into the mouth, spitting out blood into the vessel, flow into the throat.throat.

On the nose (noseband) for 30 min to put ice pack or cloth On the nose (noseband) for 30 min to put ice pack or cloth soaked in cold water.soaked in cold water.

Call to an ambulance.Call to an ambulance.

ACTION ON CALLACTION ON CALLDiagnosisDiagnosis

OBLIGATORY QUESTIONSOBLIGATORY QUESTIONS Which half of the nose started to bleed?Which half of the nose started to bleed? Does the patient spits blood?Does the patient spits blood? How long is the bleeding?How long is the bleeding? What is the volume of blood loss (in milliliters)?What is the volume of blood loss (in milliliters)? Are the symptoms of orthostasis or hypovolemia?Are the symptoms of orthostasis or hypovolemia? Have nosebleeds in the past? If there were, what Have nosebleeds in the past? If there were, what

treatment has helped?treatment has helped? Are there any diseases that may manifest Are there any diseases that may manifest

symptoms of bleeding (arterial hypertension, liver symptoms of bleeding (arterial hypertension, liver disease, alcoholism, etc.)?disease, alcoholism, etc.)?

Does acetylsalicylic acid, the lack of anti-Does acetylsalicylic acid, the lack of anti-inflammatory drugs?inflammatory drugs?

DIAGNOSTIC MEASURESDIAGNOSTIC MEASURESInspect the respiratory tract (nose, throat) and to Inspect the respiratory tract (nose, throat) and to

assess the adequacy of breathing.assess the adequacy of breathing. Identify the source of bleeding by removing the Identify the source of bleeding by removing the

blood clots to enter the nasal cavity blood clots to enter the nasal cavity vasoconstrictors: vasoconstrictors: α1-α1-adrenoceptor agonists adrenoceptor agonists (indanazolinR, phenylephrine) or (indanazolinR, phenylephrine) or α2-α2-adrenoceptor adrenoceptor agonists (xylometazoline, Naphazoline, agonists (xylometazoline, Naphazoline, oxymetazoline, tetrizolin) in the form of drops, oxymetazoline, tetrizolin) in the form of drops, spray or turundas.spray or turundas.

Estimate the magnitude of blood loss on clinical Estimate the magnitude of blood loss on clinical parameters (heart rate, blood pressure).parameters (heart rate, blood pressure).

Assess the condition of the nervous and Assess the condition of the nervous and cardiovascular systems (state of consciousness, cardiovascular systems (state of consciousness, color and moisture of the skin, mucous color and moisture of the skin, mucous membrane color, heart rate).membrane color, heart rate).

Treatment on prehospital stageTreatment on prehospital stage The ineffectiveness of first aid measures and ongoing The ineffectiveness of first aid measures and ongoing

bleeding to perform:bleeding to perform: anterior nasal tamponade (using gauze turundy, anterior nasal tamponade (using gauze turundy,

catheter "YAMIK" ballooning rubber cylinder);catheter "YAMIK" ballooning rubber cylinder); posterior nasal tamponade (tamponade with the posterior nasal tamponade (tamponade with the

ineffectiveness of the front and continued abundant ineffectiveness of the front and continued abundant epistaxis);epistaxis);

introduce a 12.5% solution (2.0-4.0 ml intravenously introduce a 12.5% solution (2.0-4.0 ml intravenously or intramuscularly);or intramuscularly);

introduce a 1% solution vikasola (2.0 mL introduce a 1% solution vikasola (2.0 mL intravenously);intravenously);

introduce a 5% solution of ascorbic acid (5,0-10,0 ml introduce a 5% solution of ascorbic acid (5,0-10,0 ml intravenously);intravenously);

introduce a 10% solution of calcium chloride (10.0 mL introduce a 10% solution of calcium chloride (10.0 mL intravenously);intravenously);

introduce a 5% solution of ε-aminocaproic acid (100.0 introduce a 5% solution of ε-aminocaproic acid (100.0 ml intravenously);ml intravenously);

carry out the correction of violations of cardiac and carry out the correction of violations of cardiac and respiratory activity (in severe epistaxis patients can respiratory activity (in severe epistaxis patients can lose over 40% of the blood).lose over 40% of the blood).

INDICATION TO HOSPITALIZATIONINDICATION TO HOSPITALIZATION Inefficiency of first aid measures.Inefficiency of first aid measures. The front and back of the nose tamponade.The front and back of the nose tamponade. Signs of significant blood loss (tachycardia, Signs of significant blood loss (tachycardia,

hypotension).hypotension). The general condition of the patient and moderately The general condition of the patient and moderately

heavy.heavy. At the primary hemorrhage At the primary hemorrhage caused by an caused by an

abnormality of the nasal cavity and paranasal sinuses, abnormality of the nasal cavity and paranasal sinuses, the patient be hospitalized in thethe patient be hospitalized in the otorinolaringologic otorinolaringologic clinic. clinic. In the hospital to remove the cause of bleeding In the hospital to remove the cause of bleeding is possible, except for the above methods the front and is possible, except for the above methods the front and rear tamponade, in different ways: cauterization of rear tamponade, in different ways: cauterization of bleeding vessels, hydraulic detachment of the mucous bleeding vessels, hydraulic detachment of the mucous membrane and perichondrium of the nasal septum, membrane and perichondrium of the nasal septum, bleeding polyp removal, ligation of the artery for: bleeding polyp removal, ligation of the artery for: lattice, the internal maxillary, external carotid, both lattice, the internal maxillary, external carotid, both external carotid artery or common carotid artery.external carotid artery or common carotid artery.

In the secondary bleeding In the secondary bleeding (symptomatic) after bleeding required hospitaliza(symptomatic) after bleeding required hospitalization in the tion in the appropriate profile hospitalappropriate profile hospital for  for treatment of the underlying disease. Stopping treatment of the underlying disease. Stopping the bleeding in this case is symptomatic event.the bleeding in this case is symptomatic event.

COMMON ERRORSCOMMON ERRORS Late diagnosisLate diagnosis in injesting blood (usually in  in injesting blood (usually in

childhood).childhood). Inefficiency of the anterior tamponadeInefficiency of the anterior tamponade

due to loose tampons.due to loose tampons. Inefficiency back tamponade Inefficiency back tamponade due to a due to a

mismatch size tampon size nasopharynx patient mismatch size tampon size nasopharynx patient or because of insufficient capacity rear pad front.or because of insufficient capacity rear pad front.

THANK YOU FOR ATTENTION!!!THANK YOU FOR ATTENTION!!!