Nosebleed (Epistaxis, Nose Bleed, Bloody Nose)

  • Medical Author:
    John P. Cunha, DO, FACOEP

    John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Nosebleed definition and facts

  • The definition of a nosebleed is simply bleeding from the blood vessels in the nose. The medical term for nosebleed is epistaxis.
  • Nosebleeds are common due to the location of the nose on the face, and the large amount of blood vessels in the nose.
  • The most common causes of nosebleeds are drying of the nasal membranes and nose picking (digital trauma), which can be prevented with proper lubrication of the nasal passages and not picking the nose.
  • Most nosebleeds can be stopped at home.
  • Consult a doctor for a nosebleed if bleeding cannot be stopped, there is a large amount of blood lost, or you feel weak or faint.
  • Chronic nosebleeds or persistent nosebleeds may need to be stopped with a heating instrument or chemical swab (cautery of the blood vessel that is causing the trouble), or application of a topical medicine called thrombin that promotes local clotting of blood.
  • A doctor may use nasal packs to stop nosebleeds when conservative measures fail.
  • Do not take aspirin or other blood thinning products when you get a nosebleed (if they are doctor-prescribed, consult your doctor before stopping any medication).

What causes nosebleeds?

The nose is a part of the body rich in blood vessels (vascular) and is located in a vulnerable position protruding on the face. As a result, trauma to the face can cause nasal injury and bleeding. The bleeding may be profuse, or simply a minor complication. 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. People are more susceptible to a bloody nose if they take medications that prevent normal blood clotting (warfarin [Coumadin, Jantoven], clopidogrel [Plavix], 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 infections are more frequent, and the temperature and humidity fluctuate more dramatically. In addition, changes from a bitter cold outside environment to a warm, dry, heated home result in drying and changes in the nose which make it more susceptible to bleeding. Nosebleeds also occur in hot, dry climates with low humidity, or when there is a change in the seasons. The following risk factors predispose people to nosebleeds:

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First Aid for Nosebleeds

If you get a nosebleed, sit down and bend forward. Sitting is preferable to lying down, since keeping the head above the level of the heart will help reduce the bleeding. Bending forward is also important. It lets the blood drain out through the nose rather than down the throat.

Hold the soft portion of your nose pinched together with your fingers until the bleeding stops. This might take five to ten minutes. Placing an ice pack across the bridge of your nose can also be helpful.

How do you stop the common nosebleed?

Most people who develop nose bleeding can handle the problem without the need of a treatment by a health-care professional if they follow the step-by-step first aid recommendations below on how to stop a nosebleed:

  1. Lean forward slightly with the head tilted forward. Leaning back or tilting the head back allows the blood to run back into the sinuses and throat, and can cause gagging or inhaling of blood.
    • Spit out any blood that may collect in your mouth and throat. It may cause nausea, vomiting, or diarrhea if swallowed.
    • Gently, blow any blood clots out of your nose. The nosebleed may worsen slightly when you do this but this is expected.
  2. Pinch all the soft parts of the nose together between the thumb and index finger.
  3. Press firmly toward the face - compressing the pinched parts of the nose against the bones of the face. Breathe through your mouth as you do this.
  4. Hold the nose for at least five minutes. Repeat as necessary until the nose has stopped bleeding.
  5. Sit quietly, keeping the head higher than the level of the heart. Do not lay flat or put your head between your legs.
  6. Apply ice (wrapped in a towel) to nose and cheeks afterwards.
  7. Oxymetazoline (Afrin), phenylephrine hydrochloride (Neo-Synephrine, Neofrin), or phenylephrine-DM-guaifenesin (Duravent) nasal spray can be used short-term to help with congestion and minor bleeding if you do not have high blood pressure. However, these sprays should not be used for more than a few days at a time, as they can make congestion and nosebleeds worse.

Stuffing cotton or tissue into your nose is not recommended.

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, for example, docusate (Colace).
  • 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.
  • Eat a diet of soft, cool foods and beverages. No hot liquids for at least 24 hours.
  • Do not take any medications that will thin the blood for example, aspirin, ibuprofen (Advil, Motrin, and others), clopidogrel bisulfate (Plavix) or warfarin (Coumadin). Do not stop taking any medications without first contacting your doctor.
  • 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 blood clots by sniffing in forcefully. A temporary remedy such as a nasal decongestant spray, for example, Afrin or Neo-Synephrine may be helpful. These types of sprays constrict blood vessels. (NOTE: If used for many days at a time, these can cause addiction so they are recommended for short-term use only. Do not use if the patient has high blood pressure.)
  • Repeat the steps above on how to stop the common nosebleed. If bleeding persists, call the doctor and/or go to the nearest emergency department.

What if a person has frequent or chronic nosebleeds?

If a nosebleed recurs four times or more in a week, see a health-care professional to determine why this is occurring. Frequent or chronic nosebleeds may be caused by many factors including

  • Frequent picking or blowing the nose
  • A low humidity environment
  • Chronic allergies
  • Medications including blood thinners, aspirin, anti-inflammatory drugs, antihistamines, decongestants, or nasal sprays
  • Health conditions that affect normal blood clotting
  • A structural problem within the nose
  • Abnormal blood vessels within the nose (for example Osler-Weber-Rendu syndrome, a hereditary condition)
  • A polyp or tumor in the nose or sinuses.
  • Use of complementary and alternative medicines such as Ginkgo biloba and vitamin E, which may increase the risk of bleeding.
  • Snorting drugs such as cocaine.

If the nosebleed persists or is recurrent, see your health-care professional who may recommend stopping the nosebleed with a heating instrument or chemical swab (cautery of the blood vessel that is causing the trouble), or application of a topical medicine called thrombin that promotes local clotting of blood. Blood tests may be ordered to check for bleeding disorders. If bleeding is still persistent, the doctor may place nasal packs, which compress the vessels and stop the bleeding. In rare situations, you may be admitted to the hospital or require surgical treatment or a procedure where material is used to plug up the bleeding vessels in the nose (angiographic embolization).

What remedies or medications can you take to prevent nosebleeds?

The most common cause of a nose bleeds is drying of the nasal membranes. If a person is prone to recurrent or frequent nosebleeds, it is often helpful to lubricate the nose with an ointment of some type. The ointment can be applied gently with a Q-tip or fingertip up inside the nose, especially on the middle portion (the septum).

Many people use remedies for nosebleeds such as

  • A + D ointment,
  • methylsalicylate/menthol (Mentholatum, BenGay, Icy Hot),
  • Polysporin,
  • neomycin/bacitracin/polymyxin (Neosporin ointment), or
  • Vaseline.
  • Saline mist nasal spray is often helpful (Ocean Spray).

Nosebleeds in children may be prevented by ensuring children do not pick their nose.

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When should you call your doctor or go to an emergency room for a nosebleed?

  • If bleeding cannot be stopped or keeps occurring (persistent or chronic).
  • If bleeding is rapid, or if blood loss is large.
  • If you feel weak or faint.
  • If your nosebleed is associated with trauma to the face, loss of consciousness, or blurry vision.
  • If your nosebleed is associated with a fever or headache.
  • If your infant or baby has a nosebleed, contact the pediatrician.

What should I do if the doctor has placed nasal packs?

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 or a gel gauze-wrapped balloon (called a "Rhino Rocket") used to help compress the area of the nose that is bleeding. The doctor usually leaves them in for several days. This requires a follow-up appointment so your doctor can remove the packs.

The patient will need someone to drive them and bring them home after the nasal packs are removed. During this time, the patient may be prescribed antibiotics and pain medication as needed.

It is not uncommon for the nose to drain a blood-tinged material. Folded gauze taped under the nose (a mustache dressing) is often useful. The doctor may permit the patient to clean the nostrils with hydrogen peroxide soaked Q-tips. Prevention methods described previously should be considered to help to avoid bleeding again.

Patients with nosebleeds should not take aspirin or any other blood thinning products. If patients are already taking these medications when the nosebleed is noticed, they should notify their doctor.

Picture of Mustache Dressing
Picture of Mustache Dressing

REFERENCES:

Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.

Alter, Harrison, MD et al. "Patient information: Nosebleeds (epistaxis) (Beyond the Basics)." UpToDate. Updated May 22, 2017.
<http://www.uptodate.com/contents/nosebleeds-epistaxis-beyond-the-basics>

Claire Shovlin, PhD, FRCP. "Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)." UpToDate. Updated: Mar 10, 2017.
<http://www.uptodate.com/contents/hereditary-hemorrhagic-telangiectasia-osler-weber-rendu-syndrome>

Suh MD, Jeffrey D. and Rohit Garg, MD, MBA. Epistaxis (Nosebleeds). 2011. 28 August 2015
<http://care.american-rhinologic.org/epistaxis>

Washington University Sinus Institute . Prevention Tips for Nosebleeds.
<http://sinus.wustl.edu/Details.aspx?ID=300>

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Reviewed on 9/21/2017
References
REFERENCES:

Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.

Alter, Harrison, MD et al. "Patient information: Nosebleeds (epistaxis) (Beyond the Basics)." UpToDate. Updated May 22, 2017.
<http://www.uptodate.com/contents/nosebleeds-epistaxis-beyond-the-basics>

Claire Shovlin, PhD, FRCP. "Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)." UpToDate. Updated: Mar 10, 2017.
<http://www.uptodate.com/contents/hereditary-hemorrhagic-telangiectasia-osler-weber-rendu-syndrome>

Suh MD, Jeffrey D. and Rohit Garg, MD, MBA. Epistaxis (Nosebleeds). 2011. 28 August 2015
<http://care.american-rhinologic.org/epistaxis>

Washington University Sinus Institute . Prevention Tips for Nosebleeds.
<http://sinus.wustl.edu/Details.aspx?ID=300>

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