Nosebleed

Nosebleed (epistaxis) is classified as anterior or posterior, depending on where it originates within the nose. Most nosebleeds are anterior, and occur along the anterior nasal septum, which divides the nares ("nostrils"). Generally, anterior nosebleed is less serious, because the victim will usually drain blood outward through the nostrils. Posterior nosebleed (10% of nosebleeds), which occurs with a greater frequency in elders, is more difficult to control, and the victim often drains blood back into the throat, with coughing and potential choking. Anterior nosebleed is more common and can usually be managed outside of the hospital. If you suspect a posterior nosebleed (bleeding from the nose accompanied by brisk bleeding into the throat, so that a lot of blood is continually swallowed, particularly after the anterior bleeding has been controlled), immediately evacuate the victim to a hospital.

The most frequent cause of a nosebleed is a small bleeding blood vessel or cut on the inner mucosal surface of a nostril. This is more common at high altitudes and in cold weather (e.g., winter), because the drying effect causes the skin to become irritated and crack. One way to prevent nosebleeds is to keep the inside of the nose lubricated with an ointment such as mupirocin or bacitracin, or to spray regularly with saline solution (such as Ocean saline mist or drops with 0.65% sodium chloride). It is possible that nosebleeds are more common in persons whose blood pressure has risen out of control, although this has never been proven and is somewhat controversial. People on prescription anticoagulant drugs are prone to nosebleeds. Low-dose aspirin, garlic, ginkgo, or ginseng ingestion may contribute to an increased frequency of nosebleeds.

To control an anterior nosebleed, attempt simple maneuvers first. Have the victim blow his nose to remove all clots. Keep him upright (sitting leaning forward) and calm, and firmly press both nostrils closed against the nasal septum (middle cartilage). A common mistake is to apply pressure against the nasal bones, rather than to press the fleshy sides of the nose against the septum. Hold this position for 15 minutes without release; letting go prior to this time will only restart the bleeding, because it takes the small blood vessels and scratched surface a while to stop oozing. After 15 minutes, let go and see if the bleeding has stopped. If not, gently but firmly pack both nostrils with a gauze or cotton roll moistened with phenylephrine 0.25% (Neo-Synephrine 1/4%) or oxymetazoline (Afrin) and repeat the pinching maneuver for 20 minutes. Generally, this does the trick; if it doesn’t, repeat the packing without the phenylephrine or oxymetazoline. After the bleeding has stopped, leave the packing in place for 2 hours and then gently remove it. Sometimes, simply spraying phenylephrine or oxymetazoline inside the nose (as one would do for a common cold) at the beginning of the compression process is enough to terminate a nosebleed. Cold (low temperature) compresses applied to the bridge of the nose or a roll of gauze or cotton placed beneath the upper lip are of limited help when dealing with a brisk nosebleed.

Packing with absorbable gelatin foam (Gelfoam) or oxidized cellulose (Surgicel) may be helpful. Another hemostatic packing gauze is QuikClot NoseBleed gauze (Z-Medica Corporation). A useful device for packing the nose to stop a nosebleed is the Rhino Rocket (Shippert Medical Technologies), which is a compressed medical-grade foam sponge with applicator. The foam is guided into place, where it swells on contact with moisture (blood) to 8 to 10 times its compressed size. A string is attached to the sponge so that it can be easily removed. Weimert Epistaxis (nosebleed) Packing or Merocel hemoX uses a similar approach. Merocel is a polyvinyl alcohol nasal tampon that is inserted into the nose, whereupon exposure to a topical vasoconstrictor (e.g., phenylephrine 0.25%) and saline causes it to expand and create pressure over the bleeding point. The rapid RHINO nasal pack with Gel Knit uses a hemostatic carboxymethylcellulose fabric over an inflatable balloon to apply compression within the nose. In one study, this device was felt to be less painful to insert and easier to remove than the Rhino Rocket. NasalCEASE (Catalina Healthcare) is a bundle of fine fibers made from brown seaweed (active ingredient calcium alginate) extract that can be inserted into the nose to aid clotting.

If the nose is packed, administer an antistaphylococcal antiseptic (such as dicloxacillin or trimethoprim-sulfamethoxazole) for the duration of the packing. The nasal packing should be kept moist with sterile saline or oxymetazoline (Afrin) spray.

A relatively new product for doctors to use to control an anterior nosebleed is FloSeal Hemostatic Matrix, which is a proprietary combination of cross-linked gelatin granules and topical human thrombin. There is a mixing process that creates a gelatinous foam that is gently injected to fill the anterior nose and stop the bleeding. The patient winds up with a comfortable nose filled with foam that breaks done in 3 to 5 days and is completely disappeared in 5 to 7 days. This is a relatively expensive treatment, but quite effective when used properly.

Some of the information in this post was derived from an excellent article entitled "Epistaxis," by Rodney J. Schlosser, M.D. (New England Journal of Medicine 2009;360:784-9)

Photo Credit: Brad Pitt: Ambler/Knapik/Splash News

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Tags: nosebleed, epistaxis, nose, wilderness medicine, outdoor medicine, healthline

Labels: epistaxis, nosebleed

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