A nose bleed is something most of us encounter at least a few times a year. Often unexpected and inconvenient, understandably we want them to end as soon as possible. Whether it’s a child, another adult or ourselves, the distress of having blood gushing out of your nose is unpleasant and knowing how to stop a nose bleed the right way will put you at ease the next time you suddenly find yourself with one. Why Do Nose Bleeds Happen?Understanding the cause of a nose bleed can help you better understand why it’s happening and how to prevent them from occurring in the future.
However, some nose bleeds have no obvious cause and may seem sporadic and unexplained. What You Should Not Do To Stop a Nose BleedBefore we tell you how to stop a nose bleed, we would like to point out a few of the techniques people sometimes use that are unhelpful:
Tilting the head back or lying down can cause blood to run down the back of your throat and into your stomach. This can irritate your stomach and cause vomiting, which can cause the nose to start bleeding again. If you or the casualty find blood making its way into your mouth, spit it out rather than swallowing and ensure you lean forward more.
Follow these steps to know how to stop a nose bleed:
If the casualty has lost a lot of blood or feels faint, seek medical aid also. Stopping a nose bleed as soon as possible will reduce distress for the casualty and all involved. Not to mention reducing the loss of blood, keeping the casualty as well as possible. With nose bleeds a common occurrence, particularly with children, knowing how to stop a nose bleed quickly and with the least amount of trauma is something everyone should know.
This protocol serves as brief introduction to epistaxis treatment measures, many of which may only be temporizing in nature. For significant or uncontrollable epistaxis, it is recommended that patients immediately be seen by the appropriate emergency response/medical professionals in their area. see also: Facial Fracture Management Handbook; Epistaxis; Anterior Ethmoidal Artery Ligation; Endoscopic Sinus Surgery; Silver nitrate use and toxicity
New Latin, from Greek, from epistazein to drip on, to bleed at the nose again, from epi- + stazein to drip. EtiologyTraumatic: digital manipulation, abrasion (post nasal intubation, feeding tube, etc), fractures, etc Infectious: bacterial URI Inflammatory: granulomatous disease, allergic rhinitis Neoplastic: papilloma (Schneiderian), fibroma (JNA), squamous cell carcinoma, etc Drug-Induced: aspirin, warfarin, other blood thinners, nasal sprays, chemo/radiation therapy Systemic: coagulopathy, HTN, thrombocytopenia, DIC, dehydration, liver failure, telangiectatic diseases (see link below)* Environmental related: dehydration of environment or seasonal air condition, nasal cannula O2, etc. *KTP laser of intra-nasal telangiectasias (HHT) (with or without Avastin injection) Some authors tend to classify epistaxis into Local and Systemic causes into which the above etiologies are then grouped. Pertinent AnatomyAnterior Bleeds: most bleeds tend to involve the region of the anterior nasal septum known as Kiesselbach's plexus or Little's area Posterior bleeds: identification of posterior bleed origin may be hard to perform without proper equipment. Woodruff's plexus: Confluence of vessels posterior to the middle turbinate that is often involved in posterior bleeds. Woodruff's plexus is formed from contributions of the sphenopalatine (from maxillary a.), ascending pharyngeal (from external carotid) and the Internal maxillary veins. Systemic disease and neoplastic disease, as well as many of the causes listed above, may lead to significant alteration of intranasal anatomy. Patients may require significant consideration for treatment beyond the scope of this protocol. However, the emphasis on clinical exam and the determination of the appropriate treatment remain of paramount importance. Pre-Exam PreparationSECURING THE AIRWAY IS THE FIRST STEP IN TREATMENT -Whether the patient is in clinic, across the hospital, or across the state, the first step should be to ensure that they have a stable airway. A pulse-oximeter should be used and attending medical staff should be available to assist as deemed necessary with each case. If the patient has a heart condition then place the patient on a cardiac monitor and make sure there is an IV placed before your arrival. Ask the ER staff to help manage elevated blood pressures. -Additionally, if the patient is awaiting your arrival, the referring medical staff involved may have the patient blow their nose and utilize vasconstrictive sprays prior to your arrival. -This should be preceded and followed by maintenance of digital pressure to the cartilaginous portion of the nose, over the inferior nasal sidewall and the lower lateral cartilage, NOT over the nasal bones more superiorly. Digital pressure should be held firmly (NO PEEKING or QUICK BREAKS) for at least 10 minutes or until arrival of treating physician/ENT. The UIHC ETC has blue clips for patients to use, which are not as effective as digital pressure, but helpful in elderly patients who cannot maintain pressure for 10 minutes (due to arthitis, etc.)
Each of these protective items should be requested prior to traveling to the ER or procured prior to treatment of patients on the wards or in clinic.
Examination- Identifying the location of the bleeding is absolutely paramount in epistaxis management. Once appropriate gowning and gloving have taken place, a head light and nasal speculum can often be utilized for initial examination. -Clot unable to be cleared by the patient should be suctioned with a large bore frazier suction (as tolerated by patient's anatomy). -The majority of bleeds will be localized to the anterior septum, often times with an area of excoriation/abrasion or hypervascularity noted. -Documentation should be noted of the side, size, accessibility of lesion and other physical exam findings, including patient's tolerance of intervention and cooperation. -If the clot is cleared anteriorly and it appears the bleed is posterior, a rigid scope and light source should be used, and suction the nose completely to enable visualization of the nasopharynx completely. -Ideally the bilateral nares will have been sprayed with topical anesthetic and vascoconstrictor once clot is evacuated. Some rapid bleeds may not be conducive to appropriate application. Utilize judgment in waiting for onset of medication versus initiation of treatment. -Based on exam findings, consider appropriate treatment measures as listed below. Treatment-Topical vasoconstrictors and digital pressure: May assist with temporizing or stopping some nose bleeds. Inspection for regions of concern and possible further treatment should be made according to presentation, history and clinical status of patient. Sometimes pledgets or a cotton ball soaked in vasoconstrictor and lidocaine can carefully be placed to slow bleeding anteriorly, and in the meantime an injection of ~1 cc of lidocaine 1% with 1:100,000 epinephrine into the greater palatine foramen bilaterally can be helpful in slowing the posterior supply's contribution. Use caution in patients with heart conditions, strongly consider placing on a monitor.
-Packing: A variety of packing may be available. If cauterization is unsuccessful, difficult to perform (in posterior bleeds for example), or if the patient is unstable then packing is indicated. The following is not an exhaustive list, but an overview of some of the more popular packs available -Foley catheter and gelatin-thrombin matrix combination (for posterior epistaxis)
Absorable packing: surgicel, nasopore and floseal. Other variants and brand names are also available.
Image 1: As seen here, Surgicel comes in sheets that may be folded or cut to size for placement as needed.
Image 2: Nasopore in its packaging. Image 3: Nasopore in its packaging. UIHC Oto utilizes 8cm Extra Firm Nasopore with cutting to size performed on utilization.
Image 4: Floseal in packaging. Image 5: Floseal prepared in applicable matrix form. Syringe and applicator allow for some mid-posterior nasal application. Temporary packing: Foley catheter, lamb's wool, strip gauze, merocel, Rhinorocket, Rapid rhino.
Image 6: The 4.5 cm, 5.5 cm and 7.5 cm Rapid Rhino devices in their packaging. Image 7: The packaging and protective wrapper removed, all three devices pre-water soaked with no air added. Image 8: The devices post-water soak and with air added. Image 9: Cautery unit in UIHC ER ENT/Ophtho room. Nursing may not be familiar with its setup, so use these images as a guide for setting up suction cautery. Grounding pad inserts on bottom right and monopolar (suction) cautery on left. Note the blue adapter which allows for connection to the monopolar. If this adapter cannot be found someone may have to hold the monopolar wire in contact while you use it. Surgical InterventionSee also: Anterior Ethmoidal Artery Ligation
Post Procedure Prevention- Avoidance of digital manipulation and trauma. -Humidified air may assist with moisturizing dry mucous membranes. Use a humidifier at home. For inpatients remove nasal cannula and use humidified face mask or face tent. -Workup of bleeding disorders or systemic diseases by appropriate services if indicated. Correct blood pressure, platelets, uremia, or INR if not contraindicated. -Nasal saline sprays and water based gels to anterior vestibule -Deliver Nasal spray medications with the contralateral hand to contralateral naris technique with avoidance of spraying septum. Consider stopping nasal steroids until episodes abate, as the preparations have alcohol that dry the septum further. References
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When treating a nose bleed the maximum time to allow for the bleeding to be controlled before seeking medical advice is?
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