Nosebleed (Epistaxis)

The typical treatment for nose bleeding can be accomplished at home.

• Nosebleeds (epistaxis, nose bleed, nosebleed) can be dramatic and frightening. Fortunately, most nosebleeds are not serious and usually can be managed at home, although sometimes medical intervention may be necessary.
• Nosebleeds are categorized based on where they originate, and are described as either anterior (originating from the front of the nose) or posterior (originating from the back of the nose).
  • Anterior nosebleeds make up most nosebleeds. The bleeding usually originates from a blood vessel on the nasal septum, where a network of vessels converge (Kiesselbach plexus). Anterior nosebleeds are usually easy to control, either by measures that can be performed at home or by a health care professional.
  • Posterior nosebleeds are much less common than anterior nosebleeds. They tend to occur more often in elderly people. The bleeding usually originates from an artery in the back part of the nose. These nosebleeds are more complicated and usually require admission to the hospital and management by an otolaryngologist (an ear, nose, and throat specialist).
• Nosebleeds tend to occur more often during winter months and in dry, cold climates. They can occur at any age, but are most common in children aged 2 to 10 years and adults aged 50 to 80 years. For unknown reasons, nosebleeds most commonly occur in the morning hours.

A nosebleed simply means that blood is coming out of the inside of the nose. Nosebleeds are one of the most common problems treated in an emergency department.

Most nosebleeds do not have an easily identifiable cause. However, trauma to the nose is a very common cause of nosebleeds. Nosebleeds can be caused by trauma to the outside of the nose from a blow to the face, or trauma to the inside of the nose from nose picking. Other conditions that predispose a person to nosebleeds include:

• exposure to warm, dry air for prolonged periods of time,
• nasal and sinus infections,
• allergic rhinitis,
• nasal foreign body (object stuck in the nose),
• vigorous nose blowing,
• nasal surgery,
• deviated or perforated nasal septum, and
• cocaine use.

Less commonly, an underlying disease process or taking certain medications may cause a nosebleed or make it more difficult to control.

• Inability of the blood to clot is most often due to blood-thinning medications such as warfarin (Coumadin), clopidogrel bisulfate (Plavix), nonsteroidal anti-inflammatory drugs (NSAIDs), or aspirin.
• Topical nasal medications, such as corticosteroids and antihistamines, may sometimes lead to nosebleeds.
• Liver disease, chronic alcohol abuse, kidney disease, platelet disorders, and inherited blood clotting disorders can also interfere with blood clotting and predispose to nosebleeds.
• Vascular malformations in the nose and nasal tumors are rare causes of nosebleeds.
• High blood pressure may contribute to bleeding, but is rarely the sole reason for a nosebleed. It is often the anxiety associated with the nosebleed that leads to the elevation in blood pressure.

Bleeding usually occurs only from one nostril. If the bleeding is heavy enough, the blood can fill up the affected nostril and overflow into the nasopharynx (the area inside the nose where the two nostrils converge), causing simultaneous bleeding from the other nostril as well. Blood can also drip into the back of the throat or down into the stomach, causing a person to spit up or even vomit blood.

Signs of excessive blood loss include:

• dizziness,
• weakness,
• confusion, and
• fainting.

Excessive blood loss from nosebleeds does not often occur.

Nosebleeds in children can be an anxiety-provoking event, both for the parent and the child. However, most nosebleeds in children are self-limiting and benign, and can typically be managed at home. As in adults, most nosebleeds in children originate in the front part of the nose.

Nosebleeds in children usually occur between 2 to 10 years of age. Nosebleeds in infants, however, are unusual and require further evaluation by a health care professional. Although most nosebleeds in children are spontaneous and occur infrequently, some children may experience more frequent, recurrent nosebleeds.

The most common cause of nosebleeds in children is from minor trauma, typically from nose picking. Other common causes of nosebleeds in a child include:

• Direct trauma to the nose
• Upper respiratory infections
• Foreign body in the nose
• Allergic rhinitis
• Exposure to warm, dry air
• Nasal medications (for example, corticosteroids)

Less common causes of nosebleeds in children include vascular malformations, leukemia, nasal tumors, and various blood clotting abnormalities. An accidental ingestion of blood-thinning medication, for example, warfarin (Coumadin, Jantoven) also is a rare cause of nosebleeds in children.

The treatment for nosebleeds in children is similar to that of adults (see Treatment section). The prognosis in children is generally excellent; however, nosebleeds caused by serious underlying medical conditions vary.

A small amount of bleeding from a nosebleed requires little intervention. For example, if a person with a cold or a sinus infection blows his or her nose vigorously and notices some blood in the tissue, the person should avoid forceful nose blowing, sneezing, and nose picking. This is usually enough to keep the bleeding from getting worse.

How to stop a nosebleed

• Remain calm.
• Sit up straight and lean slightly forward.
• Lean your head forward. Tilting your head back will only cause you to swallow the blood.
• Pinch the nostrils together and apply direct pressure with the thumb and index finger for approximately 10 minutes. Time it to make sure the nostrils are not released earlier.
• Spit out any blood in the mouth. Swallowing blood may cause vomiting.
• This technique will stop the majority of simple nosebleeds.

What to do after the bleeding has stopped

• Once the bleeding has stopped, try to prevent any further irritation to the nose, such as sneezing, nose blowing, or straining for 24 hours.
• Ice packs do not help nosebleeds.
• Exposure to dry air, such as in a heated home in the winter, can contribute to the problem. Adding moisture to the air with a humidifier or vaporizer will help keep the nose from drying out and triggering more bleeding. Another option is to place a pan filled with water near a heat source, such as a radiator, which allows the water to evaporate and adds moisture to the air.
• Nasal saline sprays or other lubricating ointments or gels also may be useful to promote tissue healing and keep the nasal passages moist.

Contact a health care professional if the person experiences the following:

• repeated episodes of nosebleeds;
• additional bleeding from places other than the nose, such as in the urine or stool;
• easy bruising;
• if the person has nosebleeds and is taking any blood-thinning medications (for example, aspirin or warfarin [Coumadin]);
• if the person has nosebleeds and any underlying disease that may affect blood clotting, such as liver disease, kidney disease, or hemophilia (inability of blood to clot); or
• if the person has nosebleeds and recently had chemotherapy.

Go to the hospital if the person with the nosebleed:

• is still bleeding after pinching the nose for 10 to 20 minutes;
• is having repeated episodes of nosebleeds over a short time or if a large amount of blood is lost;
• feels dizzy or light-headed, or feels that he or she will pass out;
• has a rapid heartbeat or trouble breathing;
• is vomiting blood;
• has a rash or temperature greater than 101.4 F (38.5 C); or
• if a health care professional instructs you to go to a hospital's emergency department.

The diagnosis of a nosebleed is generally self-evident and apparent upon seeing the patient, though some individuals may not have any active bleeding by the time they arrive to seek medical care. More importantly, however, your health care professional will need to locate the source of bleeding and determine whether the person has an anterior or posterior nosebleed. Furthermore, other less common causes of nosebleeds may need to be sought depending upon the individual's medical history and the findings on the physical exam.

• To examine the nose, the health care professional will place medications into the nostrils (usually with a cotton ball) in order to numb the inside of the nose and constrict the blood vessels in that area. Numbing medications make the examination less painful. The medication that constricts the blood vessels shrinks the nasal tissue and may even control the bleeding to make it easier to see inside this small, dark cavity and identify the exact site of bleeding. A metallic instrument called a nasal speculum is then inserted into the nostrils to visualize the inside of the nose.
• The diagnosis of a posterior nosebleed is usually made when attempts to control the bleeding with measures used for an anterior nosebleed have failed, or when an anterior source is not identified. Seeing the source of a posterior nosebleed is nearly impossible. Other findings suggestive of a posterior nosebleed include heavy bleeding from both nostrils or visualizing blood draining down the back of the throat.
• Laboratory tests are usually not needed. For severe nosebleeds, however, a blood count may be checked to assess the degree of blood loss. For individuals with blood clotting disorders or for those taking blood thinners, additional blood tests may also be ordered. If there are concerns about malignancy or other less common causes of nosebleeds, further blood tests and/or imaging studies may be considered.

Anterior nosebleed

• A minor nosebleed that has stopped may require no treatment at all. Frequently, the body will form a clot at the site of the bleeding that stops any further bleeding.
• If the source of the bleeding is from a blood vessel that is easily seen, a health care professional may cauterize it (seal the blood vessel) with a chemical called silver nitrate after applying a local topical anesthetic inside the nose. Chemical cauterization is most effective when the visible bleeding originates from the very front part of the nose.
• In more complicated cases, a nasal packing may be required to stop the bleeding. Nasal packings apply direct pressure inside the nostril to promote clotting and stop the bleeding. Many different types of nasal packings are available, including petroleum (Vaseline) gauze, balloon nasal packs, and synthetic sponge packs that expand when moistened. The decision as to which one to use is made by the health care professional.
  • Most people who receive an anterior nasal packing go home with it in place. Because these packings block the drainage pathways of the sinuses, antibiotics may be started to prevent a sinus infection. The packing is usually left in place for 48 to 72 hours.

Posterior nosebleed

• A posterior nosebleed that does not stop bleeding on its own requires admission to the hospital, as these types of nosebleeds can be very serious. In order to control the bleeding, a posterior nasal packing will be inserted by your health care professional. While different types of packings are available, a balloon nasal pack is most commonly used.
• Unlike anterior nasal packings, posterior nasal packings are much more uncomfortable and frequently require sedatives and pain medications. Furthermore, potential complications such as infection and blockage of the breathing passages may be encountered with posterior nasal packings. Consequently, admission to the hospital, close monitoring and consultation with an otolaryngologist are required.
• Posterior packings are usually left in place for 48 to 72 hours. If this does not control the bleeding, arterial embolization or certain surgical procedures may be required.

Most people can be seen and discharged from a doctor's office or from an emergency department after treatment for a nosebleed. If a nasal packing has been placed, patients should not try to remove the packing themselves. The patient needs to be seen again, usually within 2 to 3 days, at which time the packing will be removed by a health care professional. Certain patients with recurrent nosebleeds or nosebleeds complicated by various medical conditions may need to be seen by an otolaryngologist.

Try to avoid any further irritation of the nose. Do not blow the nose. Try not to sneeze or cough, if possible. Avoid any strenuous activities, such as heavy lifting or exercise.

If possible, try not to take any medications that may interfere with normal blood clotting, such as aspirin, or nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin or Advil) or naproxen (Aleve or Naprosyn). If the patient takes these medications, or others such as warfarin (Coumadin) or clopidogrel bisulfate (Plavix) for a chronic medical condition, consult with your health care professional. Acetaminophen (Tylenol) can be taken for fever or pain.

• Most nosebleeds occur during the winter in cold, dry climates. If a person is prone to nosebleeds, use a humidifier in the home. Petroleum jelly (Vaseline), antibiotic ointment, or a saline nasal spray also may be used to keep the nasal passages moist.
• Try not to pick or blow the nose too vigorously.
• If the nosebleed is related to an underlying medical condition (for example, liver disease or a chronic sinus condition), follow the health care professional's instructions to keep these medical problems under control.

With proper treatment, the vast majority of people recover from nosebleeds with no long-term effects. A minority of individuals may experience severe bleeding, which can rarely be life-threatening.