Nosebleed
Bleeding from the nose; Epistaxis
A nosebleed is loss of blood from the tissue lining the nose. Bleeding most often occurs from one nostril only.
The nose is a very vascular area of the body that contains many arterioles (tiny blood vessels) that can bleed easily. Nosebleeds occur more frequently in the winter when heated indoor air can dry the membranes of the nose. Also, air moving through the nose can also dry out the membranes and can form crusts. These crusts bleed when irritated by rubbing, picking, or blowing the nose. Occasionally, nosebleeds may indicate other disorders such as bleeding disorders, high blood pressure, or hardening of the arteries.
A nosebleed may be caused by trauma, irritation or dryness of the lining of the nose, allergic rhinitis, colds, or sinusitis. Other causes can include nasal obstruction such as a deviated septum, or foreign objects in the nose. Most nosebleeds begin on the septum, the midline, vertical cartilage that separates the nasal chambers and is lined with fragile blood vessels. This form of nosebleed is not serious and is usually easy to stop. Seek medical help if the bleeding persists after 15 to 20 minutes of treatment, nosebleeds recur, blood persistently drains down the throat, or a neck or serious head injury is suspected.
Considerations
Nosebleeds are very common. Most nosebleeds occur because of minor irritations of the inside of the nostrils or colds.
The nose contains many small blood vessels that bleed easily. Air moving through the nose can dry and irritate the membranes lining the inside of the nose. Crusts can form that bleed when irritated. Nosebleeds occur more often in the winter, when cold viruses are common and indoor air tends to be drier.
Most nosebleeds occur on the front of the nasal septum. This is the piece of the tissue that separates the two sides of the nose. This type of nosebleed can be easy for a trained professional to stop. Less commonly, nosebleeds may occur higher on the septum or deeper in the nose such as in the sinuses or the base of the skull. Such nosebleeds may be harder to control. However, nosebleeds are rarely life threatening.
Causes
Nosebleed can be caused by:
- Irritation due to allergies, colds, sneezing or sinus problems
- Very cold or dry air
- Blowing the nose very hard, or picking the nose
- Injury to nose, including a broken nose, or an object stuck in the nose
- Sinus or pituitary surgery (transsphenoidal)
- Deviated septum (tissue that divides the nose into 2 nostrils)
- Chemical irritants including medicines or drugs that are sprayed or snorted
- Overuse of decongestant nasal sprays
- Oxygen treatment through nasal cannulas
- Snorting cocaine or amphetamine
Repeated nosebleeds may be a symptom of another disease such as high blood pressure, a bleeding disorder, or a tumor of the nose or sinuses. Blood thinners, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin, may cause or worsen nosebleeds.
Home Care
To stop a nosebleed:
- Sit down and gently squeeze the soft portion of the nose between your thumb and finger (so that the nostrils are closed) for a full 10 minutes.
- Lean forward to avoid swallowing the blood and breathe through your mouth.
- Wait at least 10 minutes before checking if the bleeding has stopped. Be sure to allow enough time for the bleeding to stop.
It may help to apply cold compresses or ice across the bridge of the nose. Do not pack the inside of the nose with gauze.
Lying down with a nosebleed is not recommended. You should avoid sniffing or blowing your nose for several hours after a nosebleed. If bleeding persists, a nasal spray decongestant (Afrin, Neo-Synephrine) can sometimes be used to close off small vessels and control bleeding.
Things you can do to prevent frequent nosebleeds include:
- Keep the home cool and use a vaporizer to add moisture to the inside air.
- Use nasal saline spray and water-soluble jelly (such as Ayr gel) to prevent nasal linings from drying out in the winter.
When to Contact a Medical Professional
Get emergency care if:
- Bleeding does not stop after 20 minutes.
- Nose bleeding occurs after a head injury. This may suggest a skull fracture, and x-rays or other imaging should be taken.
- Your nose may be broken (for example, it looks crooked after a hit to the nose or other injury).
- You are taking medicines to prevent your blood from clotting (blood thinners).
- You have had nosebleeds in the past that needed specialist care to treat.
Contact your health care provider if:
- You or your child has frequent nosebleeds
- Your nose may be broken (for example, it looks crooked after a hit to the nose or other injury)
- Nosebleeds are not associated with a cold or other minor irritation
- Nosebleeds occur after sinus or other surgery
What to Expect at Your Office Visit
Your provider will perform a physical exam. In some cases, you may be watched for signs and symptoms of low blood pressure from losing blood, also called hypovolemic shock (this is rare).
You may have the following tests:
- Complete blood count with platelet count
- CT scan of the nose and sinuses or entire facial structures
- Nasal endoscopy (examination of the nose using a camera at the end of a short tube)
- Partial thromboplastin time measurements
- Prothrombin time (PT)
- Toxicology screen (screening for drug use)
The type of treatment used will be based on the cause of the nosebleed. Treatment may include:
- Controlling blood pressure
- Closing the blood vessel using heat, electric current, or silver nitrate sticks
- Nasal packing
- Reducing a broken nose or removing a foreign body
- Reducing the amount of blood thinner medicine or stopping aspirin
- Treating problems that keeps your blood from clotting normally
You may need to see an ear, nose, and throat (ENT, otolaryngologist) specialist for further tests and treatment.
I'm Dr. Alan Greene and let's talk for a moment about nosebleeds and what to do about them. First, many parents panic a bit when they see a nosebleed in their child. Worried it may be something serious like leukemia. But in an otherwise healthy child without any other symptoms, nosebleeds are very common and generally not serious at all. It's usually caused by a little nick or drying out of blood vessels right in the surface of the nose. So what do you do about it? Do you tilt your head back? Do you apply ice to the nose? Actually you treat it just like you would any other bleeding by applying direct pressure. And in the case of the nose the way you do it is pinch the nose shut like this, the sides against the middle, and hold it like that by the clock for 2 minutes. When you let go, often it will stop. If it's still bleeding, do that again but hold it for 5 minutes. Again, by the clock. It's a long time, the 5 minutes. But when you are done, almost all the time the nosebleed will be over with. If it's not, go ahead and give your doctor a call. They can give you some other instructions on what to do from there.
References
Kuan EC, Palmer JN. Epistaxis. In: Flint PW, Francis HW, Haughey BH, et al, eds. Cummings Otolaryngology: Head and Neck Surgery. 7th ed. Philadelphia, PA: Elsevier; 2021:chap 47.
Matlock AG, Pfaff JA. Otolaryngology. In: Walls RM, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia, PA: Elsevier; 2023:chap 58.
Savage S. Management of epistaxis. In: Fowler GC, ed. Pfenninger and Fowler's Procedures for Primary Care. 4th ed. Philadelphia, PA: Elsevier; 2020:chap 205.
Version Info
Last reviewed on: 7/1/2023
Reviewed by: Jesse Borke, MD, CPE, FAAEM, FACEP, Attending Physician at Kaiser Permanente, Orange County, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
