Nose bleed

(Epistaxis pronounced epis’-taxes)
The nose is a part of the body rich in blood vessels (vascular) and is situated in a vulnerable position as it protrudes on the face. As a result, trauma to the face can cause nasal injury and bleeding. The bleeding may be profuse, or simply a minor complication. Nosebleeds can occur spontaneously when the nasal membranes dry out and crack. This is common in dry climates, or during the winter months when the air is dry and warm from household heaters. People are more susceptible to a bloody nose if they are taking medications which prevent normal blood clotting warfarin (Coumadin), aspirin, or any anti-inflammatory medication]. In this situation, even a minor trauma could result in significant bleeding.

The incidence of nosebleeds is higher during the colder winter months when upper respiratory infections are more frequent, and the temperature and humidity fluctuate more dramatically. In addition, changes from a bitter cold outside environment to a warm, dry, heated home results in drying and changes in the nose which will make it more susceptible to bleeding. Nosebleeds also occur in hot dry climates with low humidity, or when there is a change in the seasons. The following factors predispose people to nosebleeds:

  • Infection
  • Trauma, including self-induced by nose picking, especially in children
  • Allergic and non-allergic rhinitis
  • Hypertension (high blood pressure)
  • Use of blood thinning medications
  • Alcohol abuse
  • Less common causes include tumors and inherited bleeding problems

How do you stop the common nosebleed?
Most people who develop nose bleeding can handle the problem without the need of a physician if they follow the first aid recommendations below:

  • Pinch all the soft parts of the nose together between your thumb and index finger.
  • Press firmly toward the face – compressing the pinched parts of the nose against the bones of the face.
  • Lean forward slightly with the head tilted forward. Leaning back or tilting the head back allows the blood to run back into your sinuses and throat and can cause gagging or inhaling the blood.
  • Hold the nose for at least five minutes. Repeat as necessary until the nose has stopped bleeding.
  • Sit quietly, keeping the head higher than the level of the heart. Do not lay flat or put your head between your legs.
  • Apply ice (wrapped in a towel) to nose and cheeks.

How do you prevent the nose from bleeding again?

  • Go home and rest with head elevated at 30 to 45 degrees.
  • Do not blow your nose or put anything into it. If you have to sneeze, open your mouth so that the air will escape out the mouth and not through the nose.
  • Do not strain during bowel movements. Use a stool softener (for example, Colace).
  • Do not strain or bend down to lift anything heavy.
  • Try to keep your head higher than the level of your heart.
  • Do not smoke.
  • Stay on a soft, cool diet. No hot liquids for at least 24 hours.
  • Do not take any medications that will thin the blood (aspirin, ibuprofen, clopidogrel bisulfate [Plavix] or warfarin [Coumadin]). If these have been prescribed by your physician, you need to contact them regarding stopping these medications.
  • Your doctor may recommend some form of lubricating ointment for the inside of the nose (see below).
  • If re-bleeding occurs, try to clear the nose of clots by sniffing in forcefully. You can temporarily use a remedy such as a nasal decongestant spray, such as Afrin or Neo-Synephrine. These types of sprays constrict blood vessels. (NOTE: If used for many days at a time, these can cause addiction so they are recommended for short-term usage. Also, do not use if you have high blood pressure.)
  • Repeat the steps above on how to stop the common nose bleed. If bleeding persists, call the doctor and/or visit to the emergency room.

What precautions can you take to prevent nose bleeding?
The most common cause of a nose bleeds is drying of the nasal membranes. If you are prone to recurrent nosebleeds, it is often helpful to try lubricating the nose with an ointment of some type. This can be applied gently with a Q-tip or your fingertip up inside the nose, especially on the middle portion (the septum). Many people use remedies for nose bleeds such as A & D ointment, Mentholatum, Polysporin/Neosporin ointment, or Vaseline. Saline mist nasal spray is often helpful (Ayr Spray).

When should you call your doctor or report to the emergency room?

  • If bleeding cannot be stopped or keeps occurring.
  • If bleeding is rapid, or if blood loss is large.
  • If you feel weak or faint, presumably from blood loss.
  • If your nosebleed is associated with a fever or headache.
  • If your infant or baby has a nosebleed, contact the pediatrician.

If the nosebleed persists or is recurrent, see your doctor, who may then recommend stopping the nosebleed with a heating instrument or chemical swab (cautery of the blood vessel that is causing the trouble) or application of a topical medicine called thrombin that promotes local clotting of blood. Blood tests may be ordered to check for bleeding disorders. If bleeding is still persistent, the doctor may place nasal packs, which compress the vessels and stop the bleeding. In rare situations, you may be admitted to the hospital or require surgical treatment or a procedure where material is used to plug up the bleeding vessels in the nose (angiographic embolization).

What should I do if the doctor has placed nasal packs?
Nasal packs are used when less conservative measures fail (see above). These packs are frequently placed in both sides of the nose. The packs are usually made of a material called “Merocel” or “Merogel which is a compressed sponge-like material or a biological gel used to help compress the area of the nose that is bleeding. The doctor usually does not remove them for several days (two to three days). This requires a follow-up appointment.

You will need someone to drive you and bring you home after the nasal packs are removed. During this time, you may be prescribed antibiotics and pain medications as needed.

It is not uncommon for the nose to drain a blood-tinged material. Folded gauze taped under the nose (a mustache dressing) is often useful. Your doctor may permit you to clean your nostrils with hydrogen peroxide soaked Q-tips. Finally, you should consider the prevention methods described above to help to avoid bleeding again.

Remember, patients with nosebleeds should not to take aspirin or any other blood thinning products. If patients are already taking these medications when the nosebleed is noticed, they should consult their healthcare practitioner.