Nysha Recent News

In the Know

November 25, 2016

By Mendy Hecht, Hamaspik Gazette

“Mommy, come quick! 

Chaim is having epistaxis again!”

When was the last time you heard that?  But chances are you have heard, “Mommy, come quick!  Chaim is having another nosebleed!”

In medical jargon, a nosebleed is known as epistaxis (pronounced ep-ih-STAK-seez).

But while nosebleeds are mostly not dangerous, and not uncommon, especially among children (and older adults), they can be dramatic.  So, here’s everything you need to know about nosebleeds—and what to do to stop one if your little Chaim gets one—to be… in the know.

Definition

Nosebleeds are divided into two types, depending on whether the bleeding is coming from the anterior (front) of the nose or posterior (back) of the nose.  Over 90 percent of all nosebleeds are anterior nosebleeds.

With anterior nosebleeds, the bleeding usually comes from a blood vessel at the very front part of the nose.  They are also usually easy to control.

Posterior nosebleeds are much less common. These tend to occur more often in elderly people.  Posterior bleeding usually comes 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) in emergency medicine.

Nosebleeds tend to occur during winter months and in dry, cold climates.  They can occur at any age but are most common in children ages two to ten and in adults ages 50 to 80.

Symptoms

Bleeding usually occurs in only one nostril.

If bleeding is heavy enough, the blood can fill up the nostril on the affected side and overflow within the nasopharynx (the area inside the nose where the two nostrils merge).  Blood may then flow from both nostrils even though only one is bleeding.

Blood from a nosebleed can also drip back into the throat or down into the stomach, causing a person to spit or even vomit blood.

Excessive blood loss due to a nosebleed is extremely rare, but it is a known symptom.  Signs of excessive blood loss include dizziness, light-headedness, confusion, or even fainting.

Home treatment

Most nosebleeds can be treated at home (or pretty much anywhere) by anyone (not just doctors).

For starters, if there’s only a little bleeding in the beginning, there’s not a lot you need to do.

A common scenario is when a person with a cold or a sinus infection blows his or her nose vigorously and notices some blood on the tissue—so to keep that bleeding from getting worse, just avoid any more vigorous nose blowing, sneezing, or inserting anything into the nose.

Such minor nosebleeds may need no treatment at all.  The body will often form a clot at the site of the bleeding to stop any further bleeding.

But for the majority of nosebleeds, here’s what to do:

Stopping nosebleeds: basic steps

  1. Remain calm.

  2. Sit up straight.

  3. Lean the head forward.  By remaining upright, blood pressure in the veins of the nose is lowered.  This discourages further bleeding.  Leaning forward will help avoid swallowing blood, which can irritate the stomach.

  4. Gently blow the nose to clear out any clotted blood.

  5. Pinch the nostrils—specifically, the soft front part of the nose that does not contain bone-like hard cartilage.  Use the thumb and index finger to pinch both nostrils shut, even if only one side is bleeding.  Breathe through the mouth.

  6. Using a timer, continue to pinch for ten minutes. (This technique puts pressure on the bleeding point on the nasal septum and often stops the flow of blood.)

  7. If the bleeding doesn’t stop, repeat these steps for up to a total of 20 minutes.

Prevent fresh bleeding

Once you stop the bleeding, your goal is to prevent any irritation to the nose.  So:

  1. Don’t blow the nose, sneeze (if avoidable), or insert anything into the nose for 24 hours.

  2. Don’t bend down for several hours.  Keep the head higher than the level of the heart.

  3. Eat a diet of soft, cool foods and beverages.  Avoid hot liquids for at least 24 hours.

  4. Avoid any strenuous activities, such as heavy lifting or exercise.

  5. Rest and/or sleep with head elevated at 30 to 45 degrees.

  6. If possible, try not to take any drugs that may interfere with normal blood clotting—including aspirin or anti-inflammatory drugs such as ibuprofen (Motrin or Advil) or naproxen (Aleve or Naprosyn).  If you take these drugs for a chronic medical condition, consult with your doctor about to what to do.  Acetaminophen (Tylenol) can be taken for fever or pain.

Exposure to dry air, like in a heated home in the winter, can contribute to the problem.  You can counteract this by adding moisture to the air with a humidifier or vaporizer.  This 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, like a radiator.  This allows the water to evaporate and adds moisture to the air.

Ice packs do not help.

Medical treatment

Call a doctor about nosebleeds:

  • If there are repeated episodes of nosebleeds

  • If there is additional bleeding from places other than the nose

  • If there is easy bruising

  • If the person is taking any blood-thinning drugs, including aspirin or warfarin (Coumadin)

  • If there is any underlying disease that may affect blood clotting, like liver disease, kidney disease, or hemophilia (inability of blood to clot)

  • If the person recently had chemotherapy

Seek emergency care from a doctor if the person:

  • Is still bleeding after pinching the nose for a total of 20 minutes

  • Is having repeated episodes of nosebleeds over a short time

  • Feels dizzy, light-headed or “about to pass out”

  • Has a rapid heartbeat or trouble breathing

  • Is coughing up or vomiting blood

  • Has a rash or temperature greater than 101.4°F (38.5°C)

  • Is instructed by his/her doctor to go to the ER

Serious anterior nosebleeds

In the unusual case of an anterior nosebleed that doesn’t stop: if doctors can see the nasal blood vessel that’s not stopping bleeding, they may seal it with a chemical called silver nitrate.  Cauterization is most effective when the bleeding is coming from the very front part of the nose.

In more complicated cases, a nasal rocket may be inserted to put pressure from inside the nostril to halt the bleeding.  Many different rockets are available, ranging from petroleum (Vaseline) gauze to balloon packs to synthetic sponge packs that expand when moistened.

Most people who get an anterior nasal rocket go home with it in place.  Because these rockets block the drainage pathways of the sinuses, antibiotics may be started to prevent a sinus infection.  The rocket is usually left in for 24 to 72 hours.

Posterior nosebleeds

To examine the nose, the doctor places medications into the nostrils, usually with a cotton ball, to numb the inside of the nose and constrict the blood vessels in that area.  This will also reduce swelling and allow the doctor to better see inside the nose.

The posterior nosebleed diagnosis is usually made when the measures used for an anterior nosebleed have failed.  Seeing the source of a posterior nosebleed is nearly impossible.

To treat a posterior nosebleed, a posterior nasal rocket is required.  Different types of rockets are available, though a balloon pack is most commonly used.

Unlike anterior nasal rockets, posterior rockets are very uncomfortable and frequently require sedatives and pain medications.  Complications can be associated, including infection and blockage of the breathing passages.  Admission to the hospital and close monitoring are required.

Posterior rockets are usually left in place for 48 to 72 hours.  If they do not stop the bleeding, surgical or radiologic procedures can be performed.

Lab tests may be done to evaluate blood loss or the effects of blood thinning drugs.

Cause

Nosebleeds are most commonly caused by drier air or environment with reduced moisture, like an over-air-conditioned bedroom in summer or a dried-out heated bedroom in winter.

They can also be caused by trauma to the nose.  Trauma to the outside of the nose, like as a blow to the face, or trauma inside the nose, like repeated irritation from a cold or even inserting objects (or fingers), can cause a nosebleed.

Less commonly, an underlying disease process like inability of the blood to clot may contribute to the bleeding.  Inability of the blood to clot is most often due to blood-thinning drugs like warfarin (Coumadin) or aspirin, commonly taken by seniors.  (That’s why nosebleeds occur more often in seniors.)  Liver disease can also interfere with blood clotting.

More rarely, abnormal blood vessels or cancerous growths in the nose cause nosebleeds.

High blood pressure may exacerbate bleeding, but is almost never the cause of bleeding.

Prevention and summary

Because the primary cause of nosebleeds is the inside of the nose drying out and cracking its blood vessels due to dry air (which is why they mostly occur in wintertime), prevention primarily consists of keep one’s immediate air environment moist—so as to keep the inside lining of the nose moist.  

So, for that extra layer of nosebleed prevention—especially if you or your child(ren) are prone, apply a thin layer coating of petroleum jelly (Vaseline) or antibiotic ointment (bacitracin, Neosporin) inside the nose with a cotton swab, especially during colder months when air is dry.  Saline nasal spray can also help moisten dry nasal membranes.

Trim your children’s fingernails; by keeping those nails short, you help discourage nose picking.

And finally, use an indoor room humidifier.  It will counteract the effects of dry air by adding moisture to your bedrooms and living spaces… and help keep you from having to deal with yet another dramatic scene of epistaxis.

The Gazette thanks our very own Abraham Berger, M.D., FACEP, veteran emergency-medicine authority and Medical Director of the NYSHA Article 16 Clinic, for critically reviewing this article.