What to do when the Nose Bleeds?

Nose bleed or Epistaxis is a fairly common problem in both children and the elderly. While it is scary when one has a nosebleed, it is more a nuisance rather than a serious problem. However in the elderly patients an uncontrolled nose bleed can present or lead to serious problems. Most of the nosebleeds happen due to trauma [injury] to the blood vessels in the front part of the nose while less commonly the more serious nosebleeds usually occur in the elderly and these happen in the Posterior or back part of the nose.

What causes nose bleeds?

The anatomy in the nose is slightly different and the blood vessels lie just beneath the thin mucosa making them more prone to damage. The reason for this anatomical arrangement is to facilitate thermoregulation i.e. control of the temperature and humidity of the air we breathe in. Also the nose is highly vascular and has a rich network of small blood vessels to facilitate thermal regulation. The Kiesselbach's plexus or the Little's area in the front of the nose on the nasal septum and the Woodruff's plexus in the posterior part of the nose are the two areas from where nose bleeds commonly occur.

The three main causes leading to nosebleeds or trauma in the form of picking the nose or rubbing the nose vigorously; blood thinning medication in the form of aspirin or other medicines that can cause anticogulation; and a history of bleeding disorders either in the patient or in his family.

In patients who have a cold or symptoms of allergic rhinitis the mucosa is Inflamed and friable, therefore easily prone to damage from even minimal trauma such as rubbing the nose. Most nose bleeds last for a short while whereas in patients with bleeding disorders or anticoagulant medication use the bleeding can be vigorous and take a long time to settledown. Also it is important to note that patients with a high blood pressure may tend to have vigorous bleeding although the high blood pressure itself does not cause nose bleeds.

How to manage an active nosebleed?

At home or self management:

It is important not to panic and to remain as calm as possible as most nosebleeds stop or settle spontaneously with application of pressure on the nose and minimal intervention.

The following 3 methods are recommended in managing an active nosebleed.

1. First apply pressure on the soft part of the nose for at least 15 minutes by the clock.

2. Second sit with your head forward and breathe through your open mouth. This will ensure that even if any blood flows to the back of your nose it will fall out through your mouth and not obstruct your airway in the throat.

3. Lastly place a wet cloth or an ice pack on your forehead or the back of your neck. It may aslo be a good idea to suck on an ice cube to help stop the nose bleed quickly

Usually most nose bleeds will settle with the above management however if in 20 minutes you have not managed to stop the nose bleed then seek medical attention.

At the Clinic/ Hospital:

An active nosebleed can be managed by chemical cautery under a local anaesthetic and this method is very effective to stop an acute nose bleed. Sometimes nasal catery may not be successful or if nasal cautery is unavailable, the nose is generally packed for at least 24 hours or more to stop the bleeding.

Nasal packing can be done with either a special type of sponge or ribbon dressing which is inserted into either one or preferably both nostrils to stop the bleeding. Occasionally a balloon catheter or what is called a posterior nasal packing may be needed if the bleeding is not controlled with simple nasal packing.

When one has their nose packed, they breathe through their mouth leading to a dry mouth. They may also experience a mild headache and they may find that the food may not taste as well because they are now unable to smell the flavours of the food. They may also experience a small degree of difficulty to swallow and may have watery eyes as the normal drainage of the tears into the nose is now blocked.

In cases of trauma or severe bleeding which is usually from the posterior part of the nose, occasionally some patients may have to undergo surgical exploration and clipping of the bleeding vessels, Also called Endoscopic Ligation of the nasal arteries.

How to prevent further Nose bleeds?

Once the active nose bleed has been managed it continues to heal under a scab for the next few days. Therefore it is important to take some precautions to prevent further nosebleeds in the immediate and also in the long term.

It is very important not to pick any scabs or crusts from inside the nose as this can restart the nose bleed. Usually an oil based Antiseptic cream is prescribed to be used for a few days after an acute nose bleed. It is also a good idea to use saline nasal drops to keep the nose clean and gently wash out any excess mucus or small crusts.

It is important to avoid blowing the nose vigorously and avoid stifling a sneeze in the immediate days after a nose bleed. It is better to sneeze with your mouth open to minimise increased pressure in the nose

Avoid hot foods or liquids and have them at room temperature or slightly warm

It may be wise to keep cool and avoid hot baths and avoiding excess sun exposure especially in hot weather

It is important not to lift any weights, strain in the toilet, avoid stressful situations as these can elevate the blood pressure and restart the nose bleed. If need be it may be better to take a mild laxative for constipation.

Avoid smoking and alcohol for at least two weeks after an active nose bleed.