Tuesday, June 23, 2009

Bloody nose: Stop a nosebleed and prevent recurrent bleeding

Why do nosebleeds occur?

In medical terminology, a nosebleed is properly called "epistaxis." Trauma from an injury is probably the most common way to develop a nosebleed. Dry weather and irritation from fingers in the nose are also commonly associated with nosebleeds. Anyone who takes blood thinning medication (such as Coumadin) or even some vitamins and supplements(such as fish oil, vitamin E, etc.) are more susceptible. Cancer patients undergoing chemotherapy may have nosebleeds due to loss of clotting factors called platelets that are destroyed by the chemo. Patients who receive oxygen therapy by means of a nasal cannula (also called "nasal prongs") may suffer nosebleeds because of the dry stream of air against the nasal tissue unless some humidity is added to the oxygen set-up. Uncommon reasons such as inherited problems of the blood vessels are disorders such as Osler-Weber-Rendu Syndrome (Hereditary Hemorrhagic Telangiectasia) or an inherited blood clotting disorders such as a type of hemophilia.

How to Stop a Nosebleed:

1. Sit or stand the person with the bleeding nose UPRIGHT with their head tilted FORWARD. This keeps the blood from going down the back of the throat and into the stomach which will cause irritation and often results in vomiting. Allow the blood to flow into a basin or onto a cloth if available. Stopping a bloody nose is the priority--you can worry about cleaning a mess later.

2. Have the person with the bleeding nose breathe through their mouth as they (or you) pinch the nose together to apply pressure. You'll know that you are doing this correctly if there is no longer visible blood coming out while you are applying the pressure. Make sure to pinch the soft part of the nose to apply pressure--the lower third of the nose, just above where the nose flares outward. Obviously if you try to pinch against the bony part of the nose you won't really be applying any pressure to the blood vessels underneath. Remember to encourage them to sit upright with their head tilted forward. In addition to applying pressure, you can also put an ice pack over the bony bridge of the nose to constrict the blood vessels even more.

3. Don't let up the pressure for at least 5 minutes--not even to take "a peek." Time this by the clock, don't wing it. You are trying to establish a clot in the bleeding vessels--steady, constant pressure is important in doing this. After 5 minutes of direct pressure, check for bleeding. If the nose is still bleeding, repeat step 2, only this time keep the steady continuous pressure going for at least 10 minutes.

4. Have you done all this with no improvement? In that case, it's time to visit the doctor or ER. Don't forget to continue pressure during transport and in the waiting room. Depending on the circumstances the ER doctor may have to resort to nasal cautery to stop the bleeding, by packing the nose with a gauze "nasal tampon," or by some other means to apply compression to the bleeding vessels.

5. All fixed? What now? After the nosebleed ask the patient to rest in a reclining position with the head elevated above the heart, limit strenuous activity for the rest of the day, and avoid bending and heavy lifting. It's okay to gently sniff, but avoid blowing the nose and if the patient must sneeze--encourage them to do so with an open mouth to minimize pressure through the nose.

6. What if the nosebleed starts up again?
  • Follow steps 1-3 again.
  • If unsuccessful in stopping the bleeding, or if the patient is experiencing any associated symptoms such as severe headache, body sweats, weakness, or shortness of breath--it's time to go to the ER. Remember to ensure that pressure is maintained in an effort to control the bleeding during the ride to the ER.
  • If the patient has already seen the doctor--review the discharge instructions and follow the written advice the physician gave--phone the doctor's office for any questions or concerns. Proceed to the ER if indicated.
  • On their website, the Ear, Nose, and Throat Associates of Corpus Christi suggest this additional advice for recurrent nosebleed: "Clear nose of all blood clots by sniffing in forcefully," and "Spray nose four times on both sides with decongestant spray (such as Afrin,® Duration,® Neo-Synephrineetc.)"

Quick sources for additional reading:
Ask Dr. Sears: About Nosebleeds
The Children's Hospital, Aurora, Colorado

Below: Jay Dolitsky, MD, Clinical Professor and Director of Pediatric Otolaryngolgy at the NY Eye and Ear Infirmary offers his expert opinion about nosebleeds in this YouTube video.

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