Patient education: Nosebleeds (epistaxis) (Beyond the Basics)
- Harrison Alter, MD, MS, FACEP
Harrison Alter, MD, MS, FACEP
- Attending Physician
- Highland Hospital – Alameda Health System, Oakland, California
- Associate Clinical Professor of Medicine, Division of Emergency Medicine
- University of California, San Francisco
- Anna H Messner, MD
Anna H Messner, MD
- Section Editor — Pediatric Otolaryngology
- Professor of Otolaryngology/Head & Neck Surgery and Pediatrics
- Stanford University
Getting a nosebleed or seeing a child get one can be dramatic and scary, but most nosebleeds are nothing to worry about. Nosebleeds (whose technical term is "epistaxis") are very common. Almost every person has had at least one in their lifetime. They are usually caused by dry air or nose-picking.
If you or your child gets a nosebleed, the important thing is to know how to manage it properly. With the right self-care, most nosebleeds will stop on their own.
This topic will outline the circumstances in which a nosebleed warrants immediate medical attention, explain proper self-care for a nosebleed, list the common causes of nosebleeds, and suggest some steps to help prevent recurrent nosebleeds.
WHEN TO SEEK HELP
There are two main types of nosebleed, and one can be more serious than the other:
●Anterior nosebleeds originate toward the front of the nose and cause blood to flow out through the nostrils. This is the most common type of nosebleed and it is not usually serious.
●Posterior nosebleeds originate toward the back of the nasal passage, near the throat. Posterior nosebleeds are less common than anterior nosebleeds, but they can be serious and can cause a lot of blood loss. Children do not usually get posterior nosebleeds.
You should seek emergency medical care if your nosebleed or your child’s:
●Involves massive bleeding or makes it hard to breathe
●Causes you or your child to become pale, fatigued, or disoriented
●Will not stop even after trying the self-care steps outlined below
●Happens after recent nasal surgery or if you have a known nasal tumor
●Occurs with other serious symptoms, such as chest pain
●Occurs after an injury, such as being hit in the face, and you are concerned that you could have other injuries (eg, broken bone)
●Will not stop bleeding and you take medications that prevent clotting, such as warfarin (brand names: Coumadin, Jantoven), clopidogrel (brand name: Plavix), dabigatran (brand name: Pradaxa), rivaroxiban (brand name: Xarelto), fondaparinux (brand name: Arixtra), or daily aspirin
●Will not stop and you have multiple bruises or other areas of bleeding, or you have had repeated nosebleeds.
If you are having symptoms such as chest pain, lightheadedness, or if bleeding is severe, you should call for emergency medical help. In the United States and Canada, this means calling 911. Do not drive yourself to the hospital and do not ask someone else to drive you. If you drive to the hospital, treatment cannot begin until you arrive in the emergency department.
If you are bleeding but do not have other symptoms, have someone else drive you to the hospital.
With the right self-care, most nosebleeds will stop on their own. Here's what you should do if you get one:
1. Gently blow your nose to get rid of some of the clots that have formed inside your nostrils. This may increase the bleeding temporarily, but that's OK. For younger children, this step is usually omitted.
2. Sit or stand while bending forward slightly at the waist. Do not lie down or tilt your head back. This may cause you to swallow blood and can lead to vomiting and other uncomfortable symptoms.
3. Grip the soft part of BOTH nostrils at the bottom of your nose (picture 1). Do not grip the bony bridge of your nose, as that will not help the bleeding, and do not apply pressure to just one side, even if the bleeding is only on one side.
4. Squeeze your nose closed for at least 5 minutes (for children) or 10 to 15 minutes (for adults), and use a clock to time yourself. Do not release the pressure every so often to check whether the bleeding has stopped. Many people hurt their chances of stopping the bleeding by releasing the pressure too soon or too often.
5. If you want, you can also apply a cold compress or ice pack to the bridge of your nose. This can help the blood vessels constrict and slow the bleeding. This step is not usually necessary, but many people like to do it.
If you follow the steps outlined above, and your nose continues to bleed, repeat all the steps once more. Apply pressure for a total of at least 30 minutes. If you continue to bleed even then, seek emergency medical care, either at an emergency room or at an urgent care clinic.
The inside of the nose has a lot of blood vessels that are close to the surface, so it's easy for them to get irritated or injured. Most nosebleeds are caused by nothing more than the irritation from dry or cold air, or by injury caused by nose-picking.
Sometimes people get nosebleeds because they are suffering from allergies or a cold, and their nose has become raw and inflamed. Other times, nosebleeds happen because of an injury to the face caused by a fall, a bike accident, or another type of trauma. Only rarely are nosebleeds caused by serious issues, such as bleeding disorders, blood vessel abnormalities, or cancer.
Medications — If you take medications to prevent blood clots, you are more likely to get nosebleeds and to have trouble stopping a nosebleed once it starts.
Examples of the medications that can cause these problems include:
●Warfarin (brand names: Coumadin, Jantoven)
●Dabigatran (brand name: Pradaxa)
●Rivaroxiban (brand name: Xarelto)
●Fondaparinux (brand name: Arixtra)
●Clopidogrel (brand name: Plavix)
If you take one (or more) of these medications and you get frequent nosebleeds, mention it to your healthcare provider.
In addition, nosebleeds can be a side effect of nose sprays used for allergy symptoms, such as budesonide (brand name: Rhinocort Allergy) or fluticasone propionate (brand name: Flonase Allergy Relief). If you use one of these sprays and you develop a nosebleed, talk to your healthcare provider about temporarily stopping the spray for one week. If you get frequent nosebleeds, you may need to completely stop using the spray. An alternate medication, such as an antihistamine pill, may be recommended. (See "Patient education: Allergic rhinitis (seasonal allergies) (Beyond the Basics)".)
What if I get repeated nosebleeds? — Frequent nosebleeds can be caused by:
●Constant exposure to dry air
●Consistent use of nasal sprays (such as those used to manage allergies or congestion)
●Snorting drugs into your nose, such as cocaine
In some cases, recurring nosebleeds can be a sign of a bleeding disorder. But when bleeding disorders are at play, there are often other clues. For example, people with bleeding disorders tend to bruise easily and may bleed more than expected after minor injuries. (See "Patient education: von Willebrand disease (Beyond the Basics)".)
If you wind up needing medical care for a nosebleed, your healthcare provider will focus first on making sure you can breathe properly and on getting the bleeding to stop. If you have lost a lot of blood, you may need IV fluids to restore the lost blood.
If the bleeding will not stop and the healthcare provider can see the source of the bleeding, he or she may stop the bleeding using a chemical or an electrical device. In severe cases, healthcare providers can pack the nostrils with a sponge, gauze, foam, or other materials that can help stop the bleeding. People with serious nosebleeds may need to have a balloon inflated deep within their nose to get the bleeding under control. (See "Approach to the adult with epistaxis".)
A healthcare provider can also check the nose for growths or tumors or for blood vessel abnormalities. A growth or tumor may be more likely if only one nostril bleeds repeatedly or if the blood is tinged with an odorous discharge. Another explanation for one-sided bleeding or odorous discharge is the presence of a foreign body. When examining children with unexplained nosebleeds, healthcare providers often find beads, rubber erasers, and even button batteries rammed deep inside the nose. (See "Evaluation of epistaxis in children" and "Management of epistaxis in children".)
If you have any suspicion that your child could have a small battery in their nose, you should immediately take your child to the emergency department. (See "Diagnosis and management of intranasal foreign bodies".)
If you get nosebleeds frequently, the following measures may help reduce the chances of getting a nosebleed:
●Use a humidifier in your bedroom while sleeping, especially when the air is very dry
●Keep your nose moist using a saline nasal spray or gel
●Avoid picking your nose, or — if you must do it — clip your fingernails to avoid injury
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Approach to the adult with epistaxis
Epidemiology and etiology of epistaxis in children
Evaluation of epistaxis in children
Management of epistaxis in children
The following organizations also provide reliable health information.
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/ency/article/003106.htm, available in Spanish)
(kidshealth.org/parent/firstaid_safe/emergencies/nose_bleed.html, available in Spanish)
- Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg 2006; 64:511.
- Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician 2005; 71:305.
- McGarry G. Nosebleeds in children. Clin Evid 2005; :399.
- Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev 2012; :CD004461.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.