nose bleeding

1. EPISTAXIS
Epistaxis also known as a nosebleed is a condition where there is active bleeding or acute
hemorrhage from the nostril, nasal cavity, or nasopharynx. This occurs when the blood vessels
inside the nose are injured or damaged.
TYPES
A. Anterior nosebleeds make up more than 90% of all nosebleeds. Anterior nosebleed is usually
from the front and lower part of the nose. The most common site of anterior bleeding is in the
nasal septum.
B. Posterior nosebleeds are much less common than anterior nosebleeds. The blood usually
originates from an artery in the back part of the nose. The blood usually drains down the back
of the throat instead of coining out the nostrils.
ETIOLOGY
a) Local Causes
 Finger nail trauma due to excessive nose picking. This is the most common cause among
the children.
 Trauma to nose or facial trauma due to road traffic accident or being hit on the nose by a
ball or fist.
 Fracture of the nasal bones.
 Iatrogenic causes include nasogastric and nasotracheal intubation.
b) Infections
 Children usually present with epistaxis due to local irritation or recent URTI.
 Viral rhinitis
 Acute sinusitis
c) Others
 Foreign bodies in nose
 Deviation of the nasal septum
 Atmospheric changes such as sudden movement to high altitudes.
 Any growth in the nasal cavity, like polyps, benign or malignant tumors
d) General Causes
 Idiopathic - at times the cause of bleeding may not be clear.

2.  Hypertension — commonly seen in old age
 Heart diseases
 Pregnancy
 Bleeding disorders
 Drugs- Topical nasal drugs such as antihistamines and corticosteroids, especially when
applied directly to the nasal septum instead of the lateral walls, may cause mild epistaxis.
 Oral anticoagulants and coagulopathy due to splenomegaly, thrombocytopenia, platelet
disorders, liver disease, renal failure, chronic alcohol use, or AIDS-related conditions
predispose to epistaxis.
 Acute infections like typhoid, pneumonia, malaria, dengue fever, measles etc.
PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONS
 Dark or bright red bleeding from one or both nostrils is the most common sign of
epistaxis.
 Patient may also have trouble breathing, smelling, or talking if blood clots block nostrils.
 If patient swallow blood, stool (bowel movements) may look black.
 Other symptoms include headache, confusion, fainting, dizziness, and weakness,
especially when lose a lot of blood.
 If the bleeding is heavy enough, the blood can fill up the affected nostril and overflow

3. into the nasopharynx, causing simultaneous bleeding from the other nostril as well.
 Blood can also drip into the back of the throat or down into the stomach, causing a person
to spit up or even vomit blood.
MEDICAL MANAGEMENT
Treatment for epistaxis aims to control bleeding and treat the underlying cause.
A. Anterior Nosebleed
A minor nosebleed that has stopped may require no treatment at all. Frequently, the body will
form a clot at the site of the bleeding that stops any further bleeding.
 If the source of the bleeding is from a blood vessel that is easily seen, a doctor may cauterize
it (seal the blood vessel) with a chemical called silver nitrate after applying a l
o
c
a
ltopical
anesthetic inside the nose.
 Chemical cauterization is most effective when the visible bleeding originates from the very
front part of the nose. In more complicated cases, a nasal packing may be required to stop
the bleeding.
 Nasal packing apply direct pressure inside the nostril to promote clotting and stop the
bleeding. Many different types of nasal packing are available, including petroleum
(Vaseline) gauze, balloon nasal packs, and synthetic sponge packs that expand when
moistened.
 The local application of a vasoconstrictive agent has been shown to reduce the bleeding time
in benign cases of epistaxis.
 The drugs oxymetazoline or phenylephrine are widely available in over-the-counter nasal
sprays for the treatment of allergic rhinitis, and may be used for this purpose
 Most people who receive an anterior nasal packing go home with it in place. Because these
packing block the drainage pathways of the sinuses, antibiotics may be started to prevent a
sinus infection. The packing is usually left in place for 48-72 hours.
Posterior Nosebleed
 A posterior nosebleed that does not stop bleeding on its own requires admission to the
hospital, as these types of nosebleeds can be very serious.
 In order to control the bleeding, a posterior nasal packing will be inserted. Different

4. types of packings are available, though a balloon nasal pack is most commonly used.
 Unlike anterior nasal packings, posterior nasal packings are much more uncomfortable
and frequently require sedatives and pain medications.
 Furthermore, potential complications such as infection and blockage of the breathing
passages may be encountered with posterior nasal packings. Consequently, admission to
the hospital and dose monitoring are required.
 Posterior packings are usually left in place for 48-72 hours. If this does not control the
bleeding, arterial embolization or certain surgical procedures may be required.
NURSING MANAGEMENT
 Lean forward to keep blood from going down the back of your throat, and breathe
through the mouth.
 Pinch the lower soft part of nose tightly using thumb and index finger for 5 to 20
minutes.
 Sit quietly, keeping the head higher than the level of the heart. Do not lay flat or put your
head between your legs.
 Ice compress can be applied in the nose. They cause bleeding blood vessels to constrict
& bleeding stops.
 After pinching your nose, release it to check if there is still bleeding. If present, repeat
pinching the nose and applying ice.
HOME CARE: AFTER DISCHARGE
 Take rest with head elevated at 30 to 45 degrees.
 Do not blow the nose or put anything into it. If you have to sneeze, open your mouth so
that the air will escape out the mouth and not through the nose.
 Do not strain during bowel movements. Use a stool softener
 Do not strain or bend down to lift anything heavy.
 Do not smoke.
 Stay on a soft, cool diet. No hot liquids for at least 24 hours.
 Do not take any medications that will thin the blood (aspirin, ibuprofen, clopidogrel
bisulfate or warfarin).
 If re-bleeding occurs, try to clear the nose of clots by sniffing in forcefully. These types

5. of sprays constrict blood vessels.
PREVENTION
 Most nosebleeds occur during the winter in cold, dry climates. If a person is prone to
nosebleeds, use a humidifier in the home.
 Petroleum jelly (Vaseline), antibiotic ointment, or a saline nasal spray may be used to
keep the nasal passages moist.
 Avoid picking the nose
 Avoid blowing the nose too vigorously.
 If the nosebleed is related to another medical condition, such as liver disease or a chronic
sinus condition, follow the doctor's instructions to keep that problem under control.
 Avoid straining while passing stools or lift anything heavy and stop smoking