Bloody Noses

The first thing to know about coming to the ER with a bloody nose is that it will stop. (In fact, the only guarantee in medicine is that all bleeding stops eventually.) And the second thing to know is that you will likely be very unsatisfied with the visit.

A couple things to know about bloody noses, referred to medically as epistaxis. The bleeding is most often from small veins along the septum of the nose. The septum is the middle part of the nose that divides your nasal passages in half. These veins are close to the surface of the mucosa/skin that lines the septum and when they get disrupted or irritated, they can bleed.

This happens from local trauma like being punched in the nose or picking your nose. It can also happen when the mucosa gets dried out or irritated from nasal congestion, seasonal changes, using nasal steroids, or pretty much for no reason at all. It just sometimes happens.

Rarely do you need to check a hemoglobin to look for anemia. Think about it—it’s a dripping faucet. It might look like gallons of blood but it’s not. The source is a tiny vein in your nose which is very different from bleeding from a large artery. Unless you are normally on the border of needing blood transfusions, which is usually at a hemoglobin of 7-8, the lab result will change nothing. That’s not to say that no bloody nose ever causes a significant amount of bleeding. But it’s exceedingly rare that it’s enough to matter. If my hemoglobin is normally 14 (in the normal range) and it drops to 12.5 (the low end of normal) because of a severe bloody nose, does that change anything?

There is disagreement about whether HTN is related to bloody noses. Patients often associate the two together, but they can coexist and not be related. (See my previous post about hammers and nails.) Long-standing HTN damages blood vessels, but whether acutely high blood pressure matters on the day you have a bloody nose is not clear. Everyone with bloody noses doesn’t have HTN, and everyone with HTN—even extreme HTN—doesn’t get a bloody nose.

If you take blood thinners, your nose can bleed easier than normal just like any injury to your body. Head bleeds are more common with blood thinners. Lacerations and skin tears bleed more. That is the entire point of blood thinners—it tips the “making clot/breaking down clot” balance in your body. I should back up here. Blood clots. That’s what it naturally does. Your body is constantly making and breaking down blood clots. When the system is in balance, you don’t bleed out from a small cut or scrape and on the other end of the spectrum, you don’t clot off an artery in your heart or brain causing a heart attack or a stroke. (As some readers may protest, “heart attack” and “stroke” are not specific but that’s not the point of this discussion. You get the idea.)

Back to the nose…

The first thing to do when you have a bloody nose is to apply pressure, the same thing that should be done for virtually any bleeding. To do this to your nose, pinch the sides of your nose together just below the bony part of your nose between your eyes. You can’t actually pinch the bones so slide your thumb and fingers down to the soft part of your nose just below the bony part and squeeze. And the most important part—keep squeezing for 15 minutes without stopping.

Patients don’t have patience. It’s not uncommon for someone with a bloody nose to squeeze for just a few minutes and then check and see if the nose is still bleeding. I have done this myself. It’s annoying to stop whatever you are doing and set aside an uninterrupted 15 mins. But every time you release pressure, the clock starts again. Most of the time, this solves the problem. What to do next is a double-edged sword.

Let’s say your nose stops bleeding, but now you have a stuffed up nose full of blood/blood clots. What do you do? Blowing it out makes sense so you can actually see if the bleeding has stopped. The downside is an aggressive blowing of your nose may again irritate the vein that was bleeding and it starts all over again.

Personally, I will blow out the clots, and if it starts bleeding again, I pack my nose with a wad of paper towel, facial tissue, or toilet paper, whatever is available and give that some time. I’ve been dealing with intermittent bloody noses since I was a kid and this has never failed to solve the problem.

A second thing you can try at home for a slowly oozing bloody nose is Afrin. It is available OTC and constricts the blood vessels in the nose, which is why it helps with nasal congestion. If you don’t try this at home, it may be one of the first things done in the ER. If a nose is bleeding more briskly, this is unlikely to work.

Cautery is something else that is commonly tried in the ER. This involves a Q-tip with silver nitrate on it that cauterizes the blood vessel. For this to be effective, there must be an identifiable vein that is bleeding and it can’t be bleeding too briskly. This hurts. The silver nitrate is activated by moisture so it will burn the vessel as well as the moist nasal tissues. If the ER provider cannot see the bleeding vessel, it’s not worth the effort to try this. Blindly rubbing silver nitrate on something you can’t clearly see is pointless and painful.

TXA is an old school medicine that helps prevent clot breakdown. Its primary use is through an IV in big trauma with internal bleeding or in an OB setting with postpartum hemorrhage. Soaking gauze with TXA and packing it in the nose is also an option. IV TXA is not used for small bleeds like noses or tooth sockets after a tooth extraction. The literature on TXA is mixed, meaning there are some studies supporting its use while others argue there is not much benefit. However, it’s a low cost and easy intervention to try.

If you’ve made it to the ER with your bloody nose and have now gotten to the point where none of these work, this is where you will start to be increasingly unsatisfied with your visit. You will get your nose packed with something large and uncomfortable. If you happen to see the device before it’s inserted in your nose, you will wonder how something that big can fit in your nose without pushing into your brain. Trust me, having done many of these, there is room. But you will certainly feel it!

The most common options are Merocels and various Rhino Rockets or Rapid Rhino. A Merocel and some Rhino products are like a small sponge that absorbs moisture and expands. The Rapid Rhino is inflated with a syringe using normal saline or air. All of them put pressure on the nasal septum to stop the bleeding. Rarely, a second device is inserted into the opposite nostril to provide even more pressure if the first one does not stop the bleeding.

Once at this point, you will go home with the device in your nose and follow up with the Ear Nose and Throat (ENT) clinic. It will be removed and they will examine your nose and see if any further interventions need to be done. The data on going home with antibiotics with one of these things in your nose is mixed. The concern is that you are clogging up the sinuses potentially causing an infection as your sinuses won’t be able to drain like they normally do as part of the normal breathing/sinus/infection-prevention system that God gave you.

In summary, do your best to NOT go to the ER with a bloody nose. We will solve the problem but you won’t enjoy the visit.

(As a side note, this discussion is about anterior epistaxis. There are exceedingly rare posterior epistaxis but I haven’t seen one that I can recall in 20+ years.)