KEYWORDS: 전비출혈 (87%) - kisselbach plexus related : 62% 다발성의 경미한 출혈로 소아나 젊은 성인에서 호발 : Caused by 외상, 염증, 구조적 원인, 이물 etc 후비출혈 (10%) 단발성의 심한 출혈로 노인에서 흔함 : Caused by 고혈압, 동맥경화증, 혈액질환 etc Epistaxis Fig 1. Nasal cavity structures related with epistaxis. Kiesselbach’s plexus (newwork of arteries in the front nasal cavity) Nose Bleeding from the nostril Posterior ethmoid arteries Hard palate(root of the mouth) Anterior ethmoid arteries Cross-secton of the nasal cavity and its vascular sources Network of arteries in the back nasal cavity Bleeding down the throat < Causes of Epistaxis > Trauma : most common Intranasal trauma : digital manipulation, blowing, wiping, decreased environmental humidity (mucosal drying,cracking) etc External nasal trauma : facial skeleton fracture etc Chemical irritation Inflammation : induces vascular engorgement and increases friability of the mucous membranes Rhinosinusitis Allergic and vasomotor rihinits Rhinitis of pregnancy Unusual rhinosinusitis : typhoid, nasal diphtheria, pertussis, ozena, malaria, other parasitic infections Wegener’s granulomatosis Vasculopathy Hypertensive vasculopathy Hereditary hemorrhagic telangiectasis Hematologic Pathology Iatrogenic (e.g., warfarin, aspirin, heparin, NSAIDs) Factor deficiencies (e.g., hemophilia, hepatic failure, vitamin K deficiency) Blood dyscrasias (idiopathic thrombocytopenia purpura, leukemia, polycythemia vera etc) Disseminated intravascular coagulation Neoplasms of the Nose, Paranasal Sinuses, and Nasopharynx Benign : hemangioma, juvenile nasopharyngeal angiofibroma, meningioma etc Malignant : squamous cell carcinoma, adenocarcinoma, lymphoma, olfactory neuroblastoma etc Other Atrophic rhinitis Vicarious menstruation 351 The Root of ambulatory care Key questions Key tests Epistaxis ..우리나라 응급실 내원환자의 통계를 보면 특발성(64%)이 가장 흔하며, 그 다 음으로 국소적 인자인 비중격 기형 (10%), 외상(8%) 및 비내 감염 (4%)이었다 는 보고가 있다. 1. The amount of blood lost/which side of the nose began? 2. Are you swallowing blood? → 후비출혈의 가능성이 크짐 3. History of nasal or facial trauma? 4. Medication? → Wafarin/Aspirin/NSAIDs 5. Past medical history → Previous epistaxis (side?), coagulopathy, easy bruising, bleeding, bleeding complications of trauma or surgery, hypertension, liver disease, rhinosinusitis, allergic rhinits 반복적으로 심한 코피가 아니라면 검사실 검사는 필요치 않다. 1. CBC (+ platelet count) 2. Bleeding time, PT, PTT ..전비 출혈인 경우 바세린거즈를 이용한 전비공 패킹으로 대부분 지혈이 가능하다. ..때때로 고혈압자체가 출혈을 악화시키며 이땐 혈압조절약제와 함께 mild anxiolytics가 유용하다. 참고 문헌 Joseph Valentino : Epistaxis,in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 77-79 이정범 : 코피, in 가정의학 임상편. 서울, 계측문화사, 2002, P 733-737 Raymond C. Hui, M.D. in the Nosebleeds(Epistaxis). Available from : URL : http://www.hughston.com/ hha/a.nosebleed.htm 353 The Root of ambulatory care