Epistaxis (Nosebleed)

How to stop a nosebleed

1. Sit up and lean forward. Do not tip your head back, which makes blood run down your throat and can cause vomiting.
2. Pinch the soft part of your nose firmly, just below the bony bridge, closing both nostrils.
3. Hold for 10 to 15 minutes by the clock without releasing to check.
4. Breathe through your mouth and spit out any blood.
5. Optional: a cold pack on the bridge of the nose or sucking on ice may help.
6. If still bleeding, gently blow out clots, spray an over-the-counter oxymetazoline decongestant twice into the bleeding side if you do not have high blood pressure or other contraindications, and pinch for another 10 to 15 minutes.
7. Afterward: avoid blowing your nose, bending, straining, heavy lifting, hot drinks and alcohol for 24 hours.

If bleeding continues after 20 minutes in total, seek emergency care.

Anterior vs posterior epistaxis

Causes of epistaxis

Local causes

• Dry air: winter heating dries and cracks the lining.
• Nose picking, rubbing and forceful blowing, especially in children.
• Colds, sinusitis and allergies: inflamed, fragile lining.
• Nasal sprays: steroid sprays aimed at the septum, or decongestant overuse.
• Injury: blows to the nose and nasal fractures.
• Deviated septum: airflow dries one area.
• Oxygen and CPAP without humidification.
• Drug use: snorting cocaine.
• Tumors: benign or malignant nasal tumors cause repeated one-sided bleeding with blockage. Juvenile angiofibroma affects adolescent boys.

General (systemic) causes

• Blood thinners and antiplatelets: warfarin, DOACs, aspirin, clopidogrel; see bleeding on anticoagulants.
• Bleeding disorders: von Willebrand disease, hemophilia, low platelets.
• Hereditary hemorrhagic telangiectasia (HHT): inherited fragile blood vessels causing frequent nosebleeds and red spots on lips and fingers.
• Liver disease and heavy alcohol use.
• High blood pressure: does not usually cause nosebleeds by itself, but can make them harder to stop.

Diagnosis

Doctors look inside the nose with a light and speculum, sometimes a thin endoscope, to find the bleeding point. Blood tests (blood count, clotting tests, INR on warfarin) are used for heavy, recurrent bleeds or suspected bleeding disorders. CT or MRI is done if a tumor is suspected.

Treatment

• Topical vasoconstrictors such as oxymetazoline to shrink vessels.
• Cautery: silver nitrate sticks or electrocautery seal an anterior bleeding vessel. Done under local anesthetic.
• Nasal packing: gauze, sponges or inflatable balloons inside the nose for 1 to 3 days. Absorbable packing is often used for people on blood thinners.
• Posterior packing: often requires admission and monitoring.
• Tranexamic acid: a medicine that helps clots form, sometimes applied topically or given by mouth.
• Endoscopic sphenopalatine artery ligation or embolization of the bleeding artery by interventional radiology, for bleeding that does not stop with packing.
• Treating the cause: adjusting blood thinners only with the prescribing doctor, treating HHT, managing tumors.

Preventing nosebleeds

• Run a humidifier in the bedroom during dry months.
• Apply saline gel or a thin layer of petroleum jelly inside the nostrils once or twice a day.
• Use saline spray regularly.
• Keep children's nails short and discourage picking.
• Aim steroid nasal sprays away from the septum (toward the outer wall of the nose).
• Avoid smoking.

Frequently asked questions

What does epistaxis mean?

Epistaxis is the medical word for a nosebleed. It comes from Greek and means "to bleed from the nose". Doctors divide it into anterior (front of the nose, most common) and posterior (back of the nose, more serious) nosebleeds.

What is the correct way to stop a nosebleed?

Sit up and lean forward, then pinch the soft lower part of your nose firmly for 10 to 15 minutes without letting go. Breathe through your mouth. Do not tilt your head back. Seek help if bleeding continues after 20 minutes.

What causes frequent nosebleeds?

Frequent nosebleeds are often caused by dry air, nose picking, allergies or colds, and nasal sprays. Blood thinners, bleeding disorders, HHT and, rarely, nasal tumors can also cause them. Recurrent bleeds, especially from one side, should be checked by a doctor.

Can high blood pressure cause nosebleeds?

High blood pressure is not usually a direct cause of nosebleeds, but it can make bleeding heavier and harder to stop. A nosebleed with very high blood pressure, headache or vision changes needs medical assessment.

When is a nosebleed an emergency?

Go to the ER if bleeding lasts more than 15 to 20 minutes despite firm pressure, is very heavy, runs down the throat, follows a significant head injury, or comes with dizziness, fainting or difficulty breathing.