HOW TO STOP A NOSEBLEED

A common, often minor, problem that causes significant anxiety for both the patient and the caregiver is the nosebleed, also known as “epistaxis”. More than 50% of the population will experience a nose bleed during their life, although only about 10% will require medical aid to stop it. Most significant bleeds will occur either at a very young age (2-10 years) or much later (50-80 years of age).

NASAL ANATOMY

The lining of the nose is supplied richly with blood vessels. When this lining is eroded, bare veins and arteries have a tendency to “leak” in a constant ooze.

About 90% of the time, the hemorrhage is coming from the front of the nose (“anterior”), near the cartilage-bearing septum. This location, known as “Little’s Area” or “Kiesselbach’s Plexus” contains numerous small arteries and veins where bleeding can originate. Bleeding comes from one nostril only in the grand majority of cases.

In a small percentage of cases, bleeding starts in back of the nose (“posterior”) where other arteries are located. These nosebleeds have a tendency to occur more often in the elderly, be heavier in volume, and more difficult to stop. The diagnosis is usually made when the usual measures for an anterior nosebleed have failed. A posterior nosebleed may be suspected by heavy bleeding from both nostrils or by blood draining down the back of the throat.

WHY NOSEBLEEDS OCCUR

Epistaxis may occur for a number of reasons. Of course, trauma to the nose and face is a common cause. This trauma may be caused by anything from a blow to the face to excessive nose-picking. Other risk factors include:

• Exposure to dry air, especially if very cold or very warm (say, from space heaters in winter)
• Sinusitis and other infections affecting the nasal cavity
• Foreign objects in the nose
• Excessively forceful nose-blowing
• Allergies
• Nasal septum abnormalities or complications from surgery to correct them
• Use of drugs inhaled through the nose. These can be recreational, such as cocaine, or therapeutic, such as afrin (oxymetazoline) or neo-synephrine. Note that Afrin and neo-synephrine are habit-forming!
• Blood clotting disorders
• Liver or kidney disease
• Chronic alcohol abuse
• Tumors in the nasal cavity
• Non-inhaled medications that “thin” the blood, like coumadin, aspirin, plavix, nsaids, etc.

High blood pressure (Hypertension) is associated with nosebleed, but it is uncertain which is the “chicken” and which is the “egg”. Is the elevated pressure causing the bleeding or does anxiety associated with seeing blood cause the blood pressure to rise?

SIGNS OF EXCESSIVE BLEEDING

Nosebleeds rarely cause life-threatening hemorrhage, but some signs may tip you off to excessive blood loss, including:

• Weakness
• Fainting
• Dizziness
• Confusion
• Rapid heart beat
• Bleeding from any place other than the nose
• The presence of fever

If modern medical facilities are available, persons with these symptoms should present there for care.

FINDING AND TREATING THE NOSEBLEED

Luckily, few nosebleeds will cause heavy bleeding and most can be treated at home by following a few general steps:

• First and foremost, stay calm. Anxiety will speed the pulse and cause more rapid bleeding.
• Sit up but not back; leaning forward will more effectively prevent blood from flowing down the back of your throat.
• Using your index finger and thumb, apply pressure by tightly pinching the area of cartilage below the bony part of the nose (pinching the bony part does little to stop the bleeding). Pinch towards the face. A commercial nasal clip is available for the purpose (see image below).
• Breathe through your mouth while holding pressure for 10 minutes.
• If the bleeding successfully stops, don’t blow your nose, bend over, or strain for the next day.
• If bleeding doesn’t stop, blow out residual clots and consider a spray like Afrin with 5-10 more minutes of pinching the nose.

If these simple instructions fail to achieve the desired result, a more thorough evaluation is warranted. To determine the location of the bleed, caregivers may spray a decongestant or saline solution into the nostrils. This will constrict the blood vessels, make visualization easier, and may even stop the bleeding. An instrument called a nasal speculum is then placed into the nostril to look inside.

If the bleeding is from an easily-seen blood vessel towards the front of the nostril, it may be cauterized with a swab stick containing a chemical called silver nitrate.

PLACING A NASAL PACK

If this fails to stop bleeding, a packing with petroleum jelly may be required to apply pressure to the leaking vessel. Other packing materials contain blood-clotting agents like Celox, which comes in a ribbon option, or drugs like oxymetazoline (Afrin) or neo-synephrine to help stop the bleed (beware of elevating blood pressures with the last two). Sometimes, synthetic sponges (Merocel) and balloons are needed to stop bleeding, especially posterior bleeding.

To place a simple anterior packing into the nose, gauze impregnated with petroleum jelly is gripped with a “bayonet” forceps and inserted into the anterior nasal cavity.  The first packing layer is inserted straight back along the floor of the anterior nasal cavity, not at an upward angle. Additional layers of packing are then added in accordion-fold fashion. A nasal speculum (pictured in a previous image) can be used to hold the positioned layers down while a new layer is inserted.  Packing is continued until the nasal cavity is filled. Be aware that you could traumatize the nasal cavity if placement is poorly performed.

It should be noted that nasal packing is an uncomfortable procedure usually performed in the emergency room. Significant pressure is usually required to be effective and the packing must stay in place for a good 48 hours or so.

A true posterior bleed may be difficult to stop without specialized equipment like balloon catheters such as the Rhino-Rocket, The Epistat catheter, or the Simpson Plug. A urinary Foley catheter balloon may also be an option to apply pressure to a posterior bleed.

Although cold temperatures are known to constrict blood vessels, it is unlikely that an ice pack would effectively deliver enough cold to the origin of the hemorrhage while at the same time allowing the application of pressure to the area. Given the choice, applying pressure is more important. Having said that, ice packs are important in nasal trauma cases to decrease swelling.

Here’s a useful video on various ways to stop a nosebleed:

PREVENTING NOSEBLEEDS

Once you’ve had a significant nosebleed, you’ll do everything possible to not have another one. Here are some strategies that will decrease the chances of a recurrence:

• Prevent nasal dryness. Moisten your nasal cavity with petroleum jelly or antibiotic ointment. Use a cotton swab to gently smear a thin layer inside several times a day, especially before going to sleep. Alternatively, use a saline nasal product. Spraying it in your nostrils helps keep the inside of your nose moist.
• Use a humidifier to increase the humidity in your home during winter.
• Don’t smoke. Smoking can dry out the inside of your nose.
• Don’t pick your nose or allow your child to do so.
• Don’t blow your nose forcefully.
• Keep fingernails short so as not to traumatize the lining (if you must pick).
• Avoid excessive use of decongestants and allergy medications, which can dry out your nose.
• Discuss other medicines you take with your health care provider to make sure they aren’t a factor in your nosebleeds.

Nosebleeds can be scary, but most can be dealt with successfully with limited supplies, even in an austere environment. With some materials and knowledge, they can be a bump on the road, not the end of the road for the prepared individual.

Joe Alton MD

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