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Nasal Bleed (Epistaxis)

The purpose of the nose is to warm and humidify the air that we breathe in. The nose is lined with many blood vessels that lie close to the surface 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. Once a vessel starts to bleed, the bleeding tends to recur since the clot or scab is easily dislodged. Nosebleeds, called epistaxis, can be messy and even scary, but often look worse than they are. 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.

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People are more susceptible to a bloody nose if they are taking medications which prevent normal blood clotting like warfarin, 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 infection is more frequent, and the temperature and humidity fluctuate more dramatically.

Common causes of nosebleeds:
  • Dry, heated, indoor air, which dries out the nasal membranes and causes them to become cracked or crusted and bleed when rubbed or picked or when blowing the nose (more common in winter months)
  • Cold (upper respiratory infections) and sinusitis, especially episodes that cause repeated sneezing, coughing, and nose blowing
  • Vigorous nose blowing or nose picking
  • The insertion of a foreign object into the nose
  • Injury to the nose and/or face
  • Use of drugs that thin the blood (aspirin, non-steroidal anti-inflammatory medications, warfarin, and others)
  • High blood pressure
  • Chemical irritants (e.g., cocaine, industrial chemicals, others)
  • Deviated septum (an abnormal shape of the structure that separates the two sides of the nose)
  • Tumors or inherited bleeding disorders (rare)
How are nosebleeds stopped?
  • Sit down and lean your body and your head slightly forward.
  • Breathe through your mouth.
  • Use a tissue or damp washcloth to catch the blood.
  • Use your thumb and index finger to pinch together the soft part of your nose. Make sure to pinch the soft part of the nose against the hard bony ridge that forms the bridge of the nose. Squeezing at or above the bony part of the put pressure where it can help stop bleeding.
  • Keep pinching your nose continuously for at least 10 minutes (timed by a clock) before checking if the bleeding has stopped. If your nose is still bleeding, continue squeezing the nose for another 10 minutes.
  • Once the bleeding stops, DO NOT bend over; strain and/or lift anything heavy and DO NOT blow, rub, or pick your nose for several days.
Under what conditions should I seek physician or emergency care?
  • You cannot stop the bleeding after more than 15 to 20 minutes of applying direct pressure.
  • You experience repeated episodes of bleeding.
  • The bleeding is rapid or the blood loss is large.
  • The bleeding was caused by an injury, such as a fall or other blow to the nose or face.
  • You feel weak or faint.
  • The blood goes down the back of your throat rather than out front through the nose even though you are sitting down with the body and head leaning slightly forward. (This may indicate the rarer, but more serious, “posterior nosebleed,” which almost always requires a physician’s care. This condition occurs more frequently in older people and individuals with high blood pressure).
  • You get a nosebleed that seems to have occurred with the start of a new medication.
  • You get nosebleeds accompanied by unusual bruising all over your body. (This combination may indicate a more serious condition and will need to be investigated by your doctor.)
How might an emergency room doctor treat the nosebleed?
  • The doctor will ask you questions about your nosebleed and examine your nose to try to determine the source of the nosebleed. He or she will use a small speculum to hold the nose open and can use various light sources or an endoscope (lighted scope) to see inside your nasal passages. Your doctor may use topical medications to anesthetize (numb) the lining of the nose and to constrict blood vessels. The doctor is also likely to remove clots and crusts from inside your nose. This can be unpleasant but need not be painful. Occasionally x-rays or blood tests are ordered.
  • Treatments, depending on the cause, could include:
  • Nasal packing – the placement of strips of gauze into the nasal cavity to create pressure on the bleeding site. Alternately, other materials that promote clotting may be used. Nasal packs are used when less conservative measures fail. These packs are frequently placed in both sides of the nose. The packs are usually made of a material called “Merocel” which is a compressed sponge-like material 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.
  • Cauterization – the application of a chemical substance (silver nitrate) or heat energy (electrocautery) to seal the bleeding blood vessel.
  • Medication adjustments – reducing or stopping the amount of blood thinning medications can be helpful. In addition, medications for controlling blood pressure may be necessary.
  • Foreign body removal
  • Repair of nasal fracture
  • Correction of a deviated septum
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.
  • 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 or warfarin). 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.
  • If re-bleeding occurs, try to clear the nose of clots by sniffing in forcefully. Control high blood pressure. Repeat the steps above on how to stop the common nose bleed. If bleeding persists, call the doctor and/or visit 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.

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