【Overview】 It is nosebleed caused by various external factors. [Treatment measures] Song Lihua, Department of Otorhinolaryngology, Affiliated Hospital of Inner Mongolia University for Nationalities I. Treatment of systemic conditions 1. Treatment of respiratory obstruction Nosebleed caused by trauma should be noted at the same time as the respiratory situation, which can be dealt with appropriately according to the severity and urgency, and those with respiratory obstruction should be lifted first. 2. Treatment of shock For those with severe bleeding, it is not appropriate to check calmly, at this time, in addition to taking immediate measures to stop bleeding, but also to quickly determine whether there is hemorrhagic shock. Nosebleeds often stop on their own after shock occurs, and should not be mistaken for healing. Attention should be paid to the symptoms of pre-shock, such as pulse block and weak, anxiety, irritability, pallor, thirst, cold sweat, chest tightness and so on. If the amount of bleeding reaches 500~1000ml, attention should be paid to heat preservation, take the side lying position, give oxygen, and immediately give intravenous fluids. When the systolic blood pressure is lower than 11.3kPa (85mmHg), it means that the blood volume has been lost more, and should be transfused promptly. Red blood cell count and hemoglobin measurement have no reference value in estimating the amount of acute nasal bleeding. 3. Application of hemostatic drugs Hemostatic drugs only play an auxiliary role in traumatic nasal bleeding. Anluo blood, hemostatic minerals are effective for capillary bleeding, 6-aminohexanoic acid is generally effective for coagulation dysfunction, and vitamin K is effective for thromboplastin reduction. II. Haemostatic methods 1.local drug hemostasis method with 1% ephedrine saline or thrombin or thrombin tightly plugged nasal cavity 5min to 2h. more dramatic blood seepage can choose a variety of hemostatic sponges, such as starch sponges, absorbable gelatin sponge, oxidized cellulose, cellulose, etc., immersed in thrombin solution, the nasal cavity is not irritating, and easy to be absorbed. Traditional Chinese medicines, such as ma bo, blood Yu charcoal end, cuttlebone, acacia, white astragalus and purple bulrush, etc., can be used for nasal bleeding after making and sterilizing. It is light on local damage and less painful for patients. The strong adhesion of Ma Bo can strengthen the destruction of platelets and help the formation of blood clots. 2. Local cautery coagulation method 1% bupivacaine for nasal mucosal surface anesthesia, or 1% procaine or 1% lidocaine with diluted isopropyl epinephrine local injection, for anesthesia and initial hemostasis, and then use the instrument or drug to make the bleeding point or small bleeding area of the local tissue coagulation to stop the bleeding. Instruments can be used high-frequency electric knife, bipolar electrocoagulators, electrocautery, transheaters or laser convergent beams, etc.; drugs can be selected from 30% to 50% silver nitrate, 50% trichloroacetic acid or pure chromic acid, etc.. Coagulation is dominated by the appearance of a distinct white film, and the drug should be used to avoid rubbing the cotton swab on the mucosa or having excess liquid flow to the healthy mucosa. It should also be noted that the coagulation should not be carried out on both sides of the nasal septum at the same time, so as to avoid perforation. 3. Plugging hemostatic method (1) anterior nostril plugging method: the first choice for serious nosebleeds. The plugging material is sterile petroleum jelly gauze. Plugging should be gradually from back to front, from top to bottom, folded, so as not to fall into the nasopharynx gauze. The gauze should be removed after 24 h to avoid sinus or middle ear complications. If prolonged blockage is needed, antibiotic powder should be added to the blockage. Airbag compression hemostasis is a modified method for anterior nostril blockage, the silicone membrane airbag with ventilation holes is placed in the nasal cavity at the possible bleeding site, and air is injected into the bag to make it expand in order to compress and stop bleeding. (2) Posterior nostril plugging method: the bleeding side of the nasal cavity by the front nostril plugging blood still flows into the pharynx or by the opposite side of the nostril gushing out, suggesting that the bleeding site in the posterior part of the nasal cavity, at this time, should be carried out after the nostril plugging. First, the petroleum jelly gauze is rolled and folded into a pillow-shaped or conical shape, slightly larger than the patient’s posterior nostril, leaving a double line about 25 cm long at each end. When blocking the first convergence and anesthesia of the nasal mucosa, with a catheter from the anterior nostril along the bottom of the nose inserted straight to the pharynx, the first end of the withdrawal from the oral cavity, tying on the blockage on the double line, and then pull the end of the catheter, drawing out the double line of the blockage, you can be blocked by the oral cavity into the nasopharyngeal part of the tight plugging of the posterior nostril, and another Vaseline gauze for the blockage of anterior nostrils (Fig. 1). The double threads at the anterior nostril are fixed with a gauze roll, and the double threads left at the oropharynx are used for pulling when the blockage is removed later. Posterior nostril blockage is usually removed within 24-36 h, otherwise it is prone to cause many complications, such as acute suppurative otitis media, acute sinusitis and osteomyelitis of the skull base. Figure 1 Posterior nostril occlusion (1. The catheter is withdrawn out of the mouth; 2. The long thread of the occlusion is tied to the end of the catheter outside the mouth; 3. The occlusion enters the nasopharyngeal cavity; 4. The occlusion is tightly plugged with the part of the posterior nostril that enters the nasal cavity and parallels to the occlusion of the nasal cavity; 5. The two long threads of the occlusion are tied to a gauze roll of the anterior nostril for fixation.) 4. Arterial ligature If the above methods fail to stop severe traumatic rhinorrhea, then arterial ligature should be carried out. Before ligating the artery, the vessel responsible for the bleeding should be identified. The blood supply to the nose comes from the external and internal carotid arteries. If the bleeding area is located above the lower edge of the middle turbinate, it is a branch of the internal carotid artery, and the anterior sieve artery should be ligated; if the bleeding area is located below the lower edge of the middle turbinate, it is a branch of the external carotid artery, and the external carotid artery or internal maxillary artery should be ligated. The anterior sieve artery can be ligated with a silk thread or clamped with a small silver clip, and it should not be cut off after ligation, so as to prevent the broken end from shrinking into the bony canal, and complications such as intraorbital hemorrhage and protruding eyeballs can occur when the ligated thread is detached. General trauma, such as digging the nose too deeply, sneezing or blowing the nose, coughing violently, inserting a nasal tube and friction with a foreign body in the nasal cavity, as well as the stimulation of dust and chemicals, etc., can cause rhinorrhea. Fighting, bumping and falling, all kinds of car accidents are easy to hurt the nose and cause bleeding. In wartime, blunt contusion, laceration, nasal bone and sinus fracture, nasal adjacent tissue injury, cranial trauma often cause severe nosebleed, often accompanied by cerebrospinal fluid leakage, and even fatal nosebleed. 2. Barometric pressure injury mostly occurs in pilots or high pressure operation staff, such as divers and tunnel operation workers, or sudden change of air pressure in nasal cavity and sinus, which can lead to sinus mucosal vascular expansion or rupture and bleeding, in the line of negative pressure replacement therapy, if the negative pressure used is too large, too long, it can also make the mucosal vascular rupture and bleeding. 3. Surgical injury is generally due to intraoperative damage to blood vessels without timely detection, or due to the operation did not take effective measures to stop bleeding. For example, if the maxillary sinus puncture through the inferior nasal tract accidentally injures the posterior lateral nasal artery, severe arterial hemorrhage can occur. Inferior turbinate resection is particularly easy to injure the nasopharyngeal venous plexus at the posterior end of the inferior nasal tract; nasopharyngeal tumor amputation can damage the pterygopalatine artery or the nasopalatine artery; maxillary sinus radical surgery, some of the postoperative 6~7d hemorrhage occurs, the bleeding point is often in the mucous membrane of the margins of the foramen ovale. Damage to the anterior or posterior sieve artery in sieve sinus surgery, or pterygopalatine artery in pterygopalatine sinus surgery when biting off the anterior wall of the pterygopalatine sinus bone, often making the surgery was forced to interrupt due to bleeding.