Nosebleed (Epistaxis)

The incidence of nosebleeds is higher during the colder winter months when upper respiratory infections are more frequent.

The definition of a nosebleed, which is medically termed epistaxis, is simply bleeding from the blood vessels in the nose. Nosebleeds are common due to the location of the nose on the face, and the large number of blood vessels in the nose.

The most common causes of nosebleeds are drying of the nasal membranes and nose picking (digital trauma), which can be prevented with proper lubrication of the nasal passages and not picking the nose.

Consult a doctor for a nosebleed if bleeding cannot be stopped, there is a large amount of blood lost, or you feel weak or faint.

The nose is a part of the body rich in blood vessels (vascular) and is located in a vulnerable position protruding 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 take medications that prevent normal blood clotting (warfarin [Coumadin, Jantoven], clopidogrel [Plavix], 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 result in drying and changes in the nose which 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 risk factors predispose people to nosebleeds:

• Infection
• Trauma, including self-induced nose picking (this is the most common cause of nosebleeds in children)
• Allergic and non-allergic rhinitis
• Hypertension (high blood pressure)
• Use of blood-thinning medications
• Alcohol abuse
• Less common causes of nosebleeds include tumors and inherited bleeding problems
• Hormonal changes during pregnancy may increase the risk of nosebleeds

If a nosebleed recurs four times or more in a week, see a healthcare professional to determine why this is occurring.

Frequent or chronic nosebleeds may be caused by many factors including:

• Frequent picking or blowing the nose
• A low-humidity environment
• Chronic allergies
• Medications include blood thinners, aspirin, anti-inflammatory drugs, antihistamines, decongestants, or nasal sprays
• Health conditions that affect normal blood clotting
• A structural problem within the nose
• Abnormal blood vessels within the nose (for example Osler-Weber-Rendu syndrome, a hereditary condition)
• A polyp or tumor in the nose or sinuses
• The use of complementary and alternative medicines such as Ginkgo biloba and vitamin E may increase the risk of bleeding
• Snorting drugs such as cocaine

If the nosebleed persists or is recurrent, see your healthcare professional who may 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 the material is used to plug up the bleeding vessels in the nose (angiographic embolization).

You should go to the emergency room for a nosebleed if you experience any of the following:

• If bleeding cannot be stopped or keeps occurring (persistent or chronic).
• If bleeding is rapid, or if blood loss is large.
• If you feel weak or faint.
• If your nosebleed is associated with trauma to the face, loss of consciousness, or blurry vision.
• If your nosebleed is associated with a fever or headache.
• If your infant or baby has a nosebleed, contact the pediatrician.

Most people who develop nose bleeding can handle the problem without the need for treatment by a healthcare professional if they follow the step-by-step first aid recommendations below on how to stop a nosebleed:

• Lean forward slightly with the head tilted forward. Leaning back or tilting the head back allows the blood to run back into the sinuses and throat, and can cause gagging or inhaling of blood.
  • Spit out any blood that may collect in your mouth and throat. It may cause nausea, vomiting, or diarrhea if swallowed.
  • Gently, blow any blood clots out of your nose. The nosebleed may worsen slightly when you do this but this is expected.
• Pinch all the soft parts of the nose together between the thumb and index finger.
• Press firmly toward the face - compressing the pinched parts of the nose against the bones of the face. Breathe through your mouth as you do this.
• Hold the nose for at least five minutes. (This time will need to be longer if taking blood thinning medication.) 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 the nose and cheeks afterward.
• Oxymetazoline (Afrin), phenylephrine hydrochloride (Neo-Synephrine, Neofrin), or phenylephrine-DM-guaifenesin (Duravent) nasal spray can be used short-term to help with congestion and minor bleeding if you do not have high blood pressure. However, these sprays should not be used for more than a few days at a time, as they can make congestion and nosebleeds worse.
• If unable to get the bleeding to stop, or at least significantly improve, in 30 minutes, especially if taking blood thinners, seek professional help from your regular healthcare team or in the Emergency Department. Continue to hold pressure while traveling.

Stuffing cotton or tissue into your nose is not recommended.

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.

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.

Nasal packs are used when less conservative measures fail. These packs are frequently placed on both sides of the nose. The packs are usually made of a material called "Merocel" which is a compressed sponge-like material or a gel gauze-wrapped balloon (called a "Rhino Rocket") used to help compress the area of the nose that is bleeding. The doctor usually leaves them in for several days. This requires a follow-up appointment so your doctor can remove the packs.

The patient will need someone to drive them and bring them home after the nasal packs are removed. During this time, the patient may be prescribed antibiotics and pain medication 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. The doctor may permit the patient to clean the nostrils with hydrogen peroxide-soaked cotton swabs (Q-tips). Prevention methods described previously should be considered to help to avoid bleeding again.

Patients with nosebleeds should not take aspirin, ibuprofen, naproxen, or any other blood-thinning products such as Ginkgo biloba and vitamin E listed above. If patients are already taking these medications when the nosebleed is noticed, they should notify their doctor.

The usage of nasal packs may result in complications. While the packs are in place, oral antibiotics are frequently recommended as a preventative step against toxic shock syndrome. The duration and usage of oral antibiotics are determined by the consultant, physician, and department. There is little compelling evidence in the literature to support the use of prophylactic antibiotics.

Other side effects of nasal packs include:

• Acute sinusitis
• Nasal blockage
• Sleep apnea
• Hypoxia
• Ulceration
• Septal perforation

Patients who have posterior packing, as well as bilateral packing, are more likely to have:

• Hypoxia episodes
• Myocardial infarction
• Cerebrovascular accident
• Death

Patients with bilateral packing or posterior packing are likely to be admitted to the hospital to avoid these complications.

The most common cause of nosebleeds is the drying of the nasal membranes. If a person is prone to recurrent or frequent nosebleeds, it is often helpful to lubricate the nose with an ointment of some type. The ointment can be applied gently with a cotton swab or fingertip up inside the nose, especially on the middle portion (the septum).

Many people use remedies for nosebleeds such as:

• A + D ointment
• methylsalicylate/menthol (Mentholatum, BenGay, Icy Hot)
• Polysporin
• neomycin/bacitracin/polymyxin (Neosporin ointment)
• petroleum jelly (Vaseline)
• Saline mist nasal spray is often helpful (Ocean Spray)

Nosebleeds in children may be prevented by ensuring children do not pick their noses.

You can attempt to prevent the nose from bleeding again with the following tips:

• Go home and rest with your 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, docusate (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.
• Eat a diet of soft, cool foods and beverages. No hot liquids for at least 24 hours.
• Do not take any medications that will thin the blood for example, aspirin, ibuprofen (Advil, Motrin, and others), clopidogrel bisulfate (Plavix), or warfarin (Coumadin). Do not stop taking any medications without first contacting your doctor.
• Your doctor may recommend some form of lubricating ointment for the inside of the nose.

If re-bleeding occurs, try to clear the nose of blood clots by sniffing in forcefully. A temporary remedy such as a nasal decongestant spray, for example, Afrin or Neo-Synephrine may be helpful. 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 use only. Do not use it if the patient has high blood pressure.)

Repeat the steps above on how to stop the common nosebleed. If bleeding persists, call the doctor and/or go to the nearest emergency department.