Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Nosebleed and Control of Nosebleed


Related Terms

  • Epistaxis

Differential Diagnosis

  • Disseminated intravascular coagulopathy (DIC)
  • Granulomatous disease
  • Hemophilia
  • Hemorrhagic telangiectasia
  • Idiopathic thrombocytopenia purpura (ITP)
  • Leukemia
  • Liver failure
  • Nasal malignancy
  • Nasopharyngeal malignancy
  • Polycythemia vera
  • Vitamin K deficiency
  • von Willebrand's disease

Specialists

  • Emergency Medicine Physician
  • Hematologist
  • Internal Medicine Physician
  • Otolaryngologist

Comorbid Conditions

  • Clotting disorders
  • Hypertension

Factors Influencing Duration

Length of disability depends on the severity of the epistaxis, underlying condition, treatment required, and any complications secondary to necessary treatment.

Medical Codes

ICD-9-CM:
21 - Operations on nose
21.01 - Operations on Nose; Control of Epistaxis by Anterior Nasal Packing
21.02 - Operations on Nose; Control of Epistaxis by Posterior and Anterior Packing
21.03 - Operations on Nose; Control of Epistaxis by Cauterization and Packing
21.04 - Operations on Nose; Control of Epistaxis by Ligation of Ethmoidal Arteries
21.05 - Operations on Nose; Control of Epistaxis by Transantral Ligation of the Maxillary Artery
21.06 - Operations on Nose; Control of Epistaxis by Ligation of the External Carotid Artery
21.07 - Operations on Nose; Control of Epistaxis by Excision of Nasal Mucosa and Skin Grafting of Septum and Lateral Nasal Wall
21.09 - Operations on Nose; Control of Epistaxis by Other Means
784.7 - Nosebleed (Epistaxis)

Overview

Epistaxis is the medical term for a nosebleed. The blood is lost from the mucous membrane lining of the nose and usually comes from one nostril. Bleeding may occur toward the front of the nose (anterior epistaxis) or much farther up inside the nose (posterior epistaxis).

Common causes of epistaxis include trauma (direct blow to the nose, nose picking, foreign bodies, forceful nose blowing, and wiping the nose), dry mucous membrane or fragile nasal vessels, or deviated septum (wall between nostrils is out of alignment causing one side to become blocked and inflamed). Epistaxis can also be the result of a cold or other infection, alcohol use, or blood thinning (anticoagulation) medication. Chemical irritation may cause nosebleeds. Nosebleeds occur more frequently when environmental humidity is low (i.e., in colder climates in the winter months).

Recurrent epistaxis can be a symptom of high blood pressure (hypertension), a bleeding disorder (coagulation disorder, anemias, leukemia, idiopathic thrombocytopenia purpura, polycythemia vera, or disseminated intravascular coagulation), or a tumor of the nose or sinuses. A nosebleed can occur with allergic rhinitis and during pregnancy (rhinitis of pregnancy).

Incidence and Prevalence: Approximately 11% of Americans experience at least one nosebleed in their lifetime. The incidence of nosebleeds requiring outpatient medical care is 15 in 10,000. The incidence of nosebleeds requiring hospitalization is 1.6 in 10,000 (Pfaff).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Although nosebleeds can occur at any age, they are most common in children aged 2-10 years and adults aged 50 to 80 years. Men are more often affected than women.

Source: Medical Disability Advisor



Diagnosis

History: Individuals report an episode of bleeding out through the nose (anterior epistaxis) or down through the mouth (posterior epistaxis). Swallowed blood may be coughed up. Individuals or family members should report the approximate amount of blood loss and on which side of the nose bleeding first began. Individuals may also have a history of taking blood thinning medications (e.g., aspirin and nonsteroidal anti-inflammatory drugs [NSAIDs]). Individuals may report a history of previous nosebleeds, easy bruising and bleeding, bleeding after surgery, hypertension, or liver disease.

Physical exam: In active epistaxis, examination of the nose reveals blood in a nostril or down the back of the throat (posterior pharynx). Posterior bleeding is more likely due to an arterial bleed. The individual is examined for signs of trauma and low fluid volume (hypovolemia) due to excessive blood loss (dizziness, loss of conscious). The pulse, respiratory rate, and blood pressure are checked. Even if the nose is not actively bleeding, nasal examination may still reveal vascular changes in the mucous membrane lining, ulcerations, small tissue growths (polyps), structural deformities (septal, turbinate), or tumors. The nose may also be completely normal upon examination.

Tests: A complete blood count (CBC) and hematocrit may be performed to rule out anemia or a condition in which the immune system reacts against the body's own tissues (autoimmune disease). However, hematocrit measurement may not accurately reflect significant blood loss since red blood cells and plasma are lost in equal proportion during acute hemorrhage. A platelet count is usually obtained. Coagulation disorders may be ruled out through tests that evaluate bleeding and clotting times, including prothrombin time and partial thromboplastin time.

Rhinoscopy refers to the magnified examination of the nose using a lighted instrument (rhinoscope). Anterior rhinoscopy is done by looking inward through the nostrils. A posterior rhinoscopy is an examination from the inside looking out into the opening between the nasal cavity and the top of the throat (posterior nares). It is usually performed using a small mirror placed in the passageway connecting the nasal cavity to the upper section of the throat (nasopharynx).

Source: Medical Disability Advisor



Treatment

The goal of treatment is to stop the bleeding and prevent recurrences. For anterior bleeding, direct pressure is applied to the bleeding site by squeezing the nostrils against the septum. If the bleeding does not stop with 15 minutes of direct pressure, the site of the bleed must be identified. Procedures used to visualize the bleeding site include examination through the nostrils (anterior rhinoscopy) and use of an illuminated instrument (nasal endoscopy). Solutions may be used that cause vasoconstriction or stop the bleeding of the blood vessels in the nose. If necessary, the bleeding site may be cauterized by electric cautery. Local anesthetic is used.

When pressure or cauterization is unable to control the bleeding, it may be necessary to pack the nasal passages. Both anterior and posterior bleeding can be packed. Packing may be performed with long strips of gauze or nasal tampons or sponges. When packing is placed, antibiotic coverage is necessary to prevent sinusitis and toxic shock syndrome. Analgesics may also be prescribed, if needed.

Cauterization is not recommended if bleeding is due to bleeding abnormalities because the procedure itself may cause bleeding. In this case, petrolatum gauze packing is applied. If recurrent bleeding is from a deviated septum, surgical correction (septoplasty) may be required. Anterior nasal packing is left in place for 2 to 3 days and then removed by the physician in an office procedure.

Posterior bleeding is more difficult to control and can be life-threatening. These bleeds usually result from underlying medical conditions such as high blood pressure or bleeding disorders. A surgical posterior rhinoscopy performed by an ear, nose, and throat specialist (otolaryngologist) may be necessary to identify the bleeding site. Nasal endoscopy may also be used to identify the bleeding site.

Procedures to control posterior bleeding include injection of vasoconstrictive medications, packing, placement of a catheter in the nose to provide pressure, placement of balloon devices (similar to that of a catheter but specially made for placement in the posterior nose), cauterization, or binding or tying off of associated nasal arteries (ligation). A neuroradiologist may also perform a procedure in which clotting material is injected into an arterial bleeder in the nose that occludes the artery at the bleeding site (angiographic procedure called angiographic embolization). In extreme cases, bleeding may have to be controlled with surgical correction. Packing is uncomfortable, and often pain and sedative medications are given during the procedure. Antibiotics and analgesics are prescribed while the packing is in place. Angiography may be necessary if surgical packing has not been successful for stopping the nosebleed.

If treatment includes posterior packing, the individual is usually hospitalized for observation of cardiac arrhythmias, respiratory failure, aspiration, cerebral vascular accident (CVA), and hypoxia. Oxygen may be necessary for treatment of hypoxia.

Source: Medical Disability Advisor



Prognosis

A complete recovery is expected. Prevention of recurrent epistaxis that is a symptom of an underlying condition depends on correction or maintenance of the predisposing factor.

Source: Medical Disability Advisor



Complications

Predisposing factors (bleeding disorders, high blood pressure, chronic inflammation, metabolic disorders, and structural deformities) may make bleeding more difficult to control and can be life-threatening. Appropriate treatment is necessary to stop the bleeding.

Posterior bleeding is more often arterial and severe. Posterior bleeding is more likely to be associated with underlying medical conditions, including hypertension, atherosclerosis, and clotting abnormalities. These conditions occur more frequently in the elderly.

If packing is placed (either anterior or posterior), sinusitis or toxic shock (very rare) may occur. There is a risk of stroke with embolization procedures.

There is an increased risk of arrhythmias, respiratory problems, and hypoxia (low blood oxygen) with posterior packing.

Enemas and cathartics may be needed to evacuate swallowed blood from the gastrointestinal tract in individuals with liver disease. The absorption of byproducts from the breakdown of blood can lead to coma in individuals with liver disease.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Restrictions or accommodations depend on the cause of the nosebleed and the risk of triggering additional nosebleeds due to the type of work activities performed or the work environment. Individuals may need to avoid excessively dry and/or cold environments. Individuals with posterior nasal packs may have significant work restrictions, depending on the job activity.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was the epistaxis anterior or posterior?
  • Was blood in a nostril or going down the back of the throat (more often indicative of an arterial bleed)?
  • Did individual cough up blood?
  • Did individual note how much blood was lost and from which nostril the bleeding started?
  • Has individual experienced trauma to the nose such as a direct blow to the nose, nose picking, foreign bodies, or forceful nose blowing?
  • Does individual use alcohol or have a cold or other infection?
  • Has individual been taking blood-thinning medications (e.g., NSAIDs)?
  • Has individual been exposed to an environment that is low in humidity?
  • Is there a history of nosebleeds or of easy bruising and bleeding? If so, does individual have hypertension or liver disease?
  • Were signs of trauma visible? Has individual been dizzy or lost consciousness?
  • Were the pulse, respiratory rate, and blood pressure abnormal?
  • Were there vascular changes in the mucous membrane lining, ulcerations, polyps, structural deformities, or tumors present on examination?
  • Was the nose completely normal upon examination?
  • Was a CBC and hematocrit performed (to rule out anemia or an autoimmune disease)?
  • Was a platelet count obtained?
  • Were prothrombin time and partial thromboplastin time obtained?
  • Was rhinoscopy performed?

Regarding treatment:

  • Did bleeding stop after 15 minutes of direct pressure? If not, was cauterization required? Did the nasal passages require packing? If so, is individual on antibiotics and analgesics?
  • Did individual require septoplasty?
  • Was posterior bleeding controlled? If not, what treatments were administered? Vasoconstrictive medication, packing, catheter placement?
  • Was cauterization or ligation required?

Regarding prognosis:

  • Has the bleeding recurred?
  • Is individual being treated for underlying conditions such as hypertension, liver disease, bleeding disorders, structural deformities, and metabolic disorders?
  • How severe and frequent are his or her nosebleeds?
  • Was packing successful?
  • Has individual experienced any complications? If so, what was the complication and how will it be treated?
  • What is the expected outcome of this complication?

Source: Medical Disability Advisor



References

Cited

Pfaff, James A., and P. Gregory. "Otolaryngology." Rosen's Emergency Medicine. Ed. J. A. Marx. 5th ed. St. Louis: Mosby, Inc., 2002. 928-938.

Source: Medical Disability Advisor






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