Nosebleed (Epixtaxis)

Dr. Terry Murphy

ED Medical Director

Samaritan Hospital

The nasal passages are a primary passage way for air to get into the lungs during breathing.  The tissues lining the nasal passages (mucous membranes) filter and warm the air before it gets to the lungs.  Mucous membrane is delicate tissue that has a very rich supply of blood vessels very near the surface. Because mucous membrane is delicate and in an exposed area of the nose, it is very susceptible to injury, and because it has so many blood vessels, it is very easy to cause bleeding from the lower part of the nose. Fortunately, this anterior epistaxis can almost always be managed very easily. 

Unfortunately, however, bleeding from the back part of the nose (posterior epistaxis) is much more difficult to stop; usually causes blood to run down the back of the throat, and often requires physician intervention.

There are a number of medical conditions, medications and behaviors that make some people more likely to experience nosebleeds, including:

– hot, dry air that occurs in geographic areas of low humidity and higher temperatures

– change of seasons, especially fall to winter, before nasal tissues have had the opportunity to adapt.  This is why nosebleeds are so common in winter when people are exposed to warn, forced air, furnace heat.

– extremes of age, that is, children often traumatize the tissues of their nose by overzealous attempts at cleaning dried secretions with their fingers while older people have thinner nasal passage lining and more friable blood vessels that occurs with aging.

– upper respiratory tract infections or inflammations (e.g. allergies) cause increased blood flow through the blood vessels of the nasal passages making them more susceptible to injury from rubbing with a tissue, or forceful nose blowing.

– many medications are implicated from making the nasal passage lining thinner from long term prednisone use to aspirin, ibuprofen (Advil, Motrin) or warfarin (Coumadin); which reduce the ability of the blood to form a clot/stop bleeding.  It is important common for people with upper respiratory tract infections, a risk factor for nose bleeding itself, to use over-the-counter cold meds that contain aspirin or ibuprofen.

– hereditary bleeding disorders, kidney failure and high blood pressure are all conditions that increase the risk of nosebleeds.  Consider also, that these diseases are more common in elderly who are already at increased risk from thinner nasal passage lining, and may be on oral anticoagulation medication.

Measures to prevent nosebleeds are aimed at the causes:

– avoiding anterior nasal injury from excessive rubbing, “picking” or too     forceful blowing

– use of a humidifier in your home when the furnace is being used

– use salt water nasal spray during the day and/or petroleum jelly applied to     the front of the nose at night to avoid drying on the nasal passage lining

– cessation of cigarette smoking

Most nosebleeds can be stopped without a physician’s care by following simple first aid maneuvers:

– sit upright with your head held forward so that the blood runs out your nose.  Lying down or holding your head back will make blood run down the back of your throat and could gag or choke you.

– using your thumb on one side and your index finger on the other of your nose, pinch the entire front part of your nose (below the bone on each side).  Keep pinching continuously for at least five minutes.  Use a watch or clock to time the five minutes, as guessing when five minutes has passed almost always under estimates the time.

– if your nose continues to bleed or starts again, resume the pinching for at least another 10 minutes.

– if, after 10 additional minutes, your nose continues to bleed or it restarts bleeding, put Neosynephrine or Afrin solution on a cotton ball and place the cotton ball in the side of your nose that is bleeding and pinch for another 10 minutes.

– if these measures fail, if you are on anti-coagulation medication or if blood continues to run down the back of your throat, you should see your doctor or go to an Emergency Department.

Physician management of persistent anterior or any posterior epistaxis usually involves several procedures:

– correcting any blood pressure abnormalities

– correcting any blood clotting abnormalities

– removing all the blood from the nostrils so that a thorough exam can be performed

– attempting to control bleeding with Neosynephrine or Afrin spray & pressure for 10 minutes

– using of either chemical (silver nitrate) or electric cautery

– using nasal packing, either packing material or a type of balloon to compress the bleeding site – this generally will need to be left in place for at least 2 days before removal

– using an inflatable balloon to control posterior bleeding

Almost everyone with a balloon to control posterior bleeding, anyone on Coumadin or with a blood clotting disorder, or anyone with too high or too low of a blood pressure will require hospitalization.

This article is intended to provide useful information, not medical advice. This information cannot, and is not meant to, replace consultation with your physician regarding your individual circumstances.