Treatments: Nosebleed (Epistaxis)
This page describes how an active nosebleed is managed.
Keep in mind that this page is not medical advice, but rather information that may supplement understanding. The advice of a personal physician takes precedence. Call 9-1-1 in case of an emergency. Patients who recently underwent rhinoplasty or other nose surgery with splints or packs in the nose should follow their surgeon’s advice.
Treatment of a nosebleed is based on addressing the multiple causes of a nosebleed.
Recommendations often include:
Constricting nasal blood vessels with a decongestant spray
Pinching the nostrils
Lowering the blood pressure
Medical follow-up. Following up with a doctor is especially important if bleeding does not stop, if blood pressure remains high, nosebleeds are recurrent, or if the total amount of blood loss is large.
See below for further elaboration.
See also this nosebleed FAQ for patients.
Medical professionals may wish to see these resources for epistaxis management.
Oxymetazoline (Afrin, Sinex) and phenylephrine (NeoSynephrine) are commonly used to help stop nosebleeds.
Medication to constrict nasal blood vessels
As a mainstay of successful management of a nosebleed, use of a medication that constricts blood vessels within the nose is generally very effective. These medications cause the diameter of the blood vessels feeding the nasal lining to shrink, thus helping slow blood flow and development of a clot.
Medications that help constrict blood vessels include oxymetazoline (Afrin, Sinex) and phenylephrine (NeoSynephrine). Available over-the-counter, these sprays are used in both nostrils as soon as possible after a nosebleed starts. Blowing the nose immediately prior to using the spray may help allow the spray to contact its target, the lining of the nose, rather than being blocked by the blood clot.
Pinch the nostrils closed.
Pinching the nostrils closed
The nostrils are pinched closed with the head leaned forward (downward) slightly, breathing through the mouth. The nostrils are typically kept pinched for at least 5 minutes, without checking for bleeding any more frequently than that.
Pinching the nostrils closed has two purposes:
Since the source of most nose bleeds is at the front of the nose, pinching the nostrils applies pressure directly on the bleeding tissue.
A pool of immobile blood begins to form in the nose. It may fill the nose, building from nostrils toward the throat. By letting still blood sit, it will be better able to form a clot.
Lower the blood pressure
Outside of a medical setting, one has the ability to lower blood pressure by calming the mind and body. Sitting down, breathing slowly, and thinking calming thoughts may help.
A blood pressure device, if available, may be used with someone’s assistance (since one hand will be pinching the nose). If blood pressure is much higher than usual, medical attention may be needed for this issue in and of itself.
Unhelpful actions.
The following actions are generally considered unhelpful:
Tilting the head back. This may stop blood from flowing out the front of the nose, but it allows blood to flow continuously to the back of the throat. Blood in the stomach is nauseating. It is difficult to estimate amount of blood loss when some blood is in the stomach.
Placing gauze or tissue within the nose. This can further abrade the surface lining of the nose and increase the area of traumatized tissue.
Pinching the nose anywhere other than the nostrils. I have heard some people advocate for pinching the nose higher and further from midline in an effort to pinch off the larger facial angular arteries that supply some blood to the nose. This is difficult to do effectively and as the nose has abundant blood supply from other arteries, is not very effective.
Cauterization
Cauterization of blood vessel(s) causing epistaxis may be undertaken in the right setting. This treatment is usually reserved for recurrent nosebleeds where the source of bleeding can be identified, and when the patient has neither excessively thin blood nor very high blood pressure. When more conservative methods, such as those outlined above, have failed, cauterization may be considered. Cauterization is usually performed by an otolaryngologist (ENT) in their office or in the operating room, and typically with a chemical (silver nitrate) or electrocautery. To avoid creating a hole in the nasal septum (septal perforation), corresponding left and right sides of the septum are not cauterized at the same time.
Nasal packing
Nasal packing may be necessary if other, less invasive, methods to control bleeding fail. Nasal packing is typically performed by staff in the emergency room or by an otolaryngologist (ENT). Packing works by applying pressure to the source of the bleeding and facilitating formation of a clot. Having a pack in the nose is uncomfortable, unfortunately, and a pack generally needs to be left in place for about five days before removal for there to be a decent chance of avoiding repeat bleeding and re-packing. During these five days, a person may address high blood pressure or medications that “thin” the blood with their physician.
Surgical ligation of blood vessels
When the above measures, including nasal packing, fail to control epistaxis, surgery to ligate or cauterize specific blood vessels feeding the nose may be undertaken. This may involve an incision on the skin between the eye and the nose, or possibly an incision in the mouth above the gums.
Embolization
Embolization is a procedure utilized by interventional radiology to manage severe epistaxis, particularly when traditional methods have failed.
During embolization, the interventional radiologist uses imaging guidance, typically fluoroscopy or CT, to identify the source of bleeding. Once the source is located, a catheter is inserted into the blood vessel, and materials that block blood flow are deployed at the targeted site.
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