Nosebleed

The lining of your nose is filled with many tiny blood vessels. These blood vessels are fragile and bleed easily if disturbed. When this occurs, blood flows out one or both your nostrils. Blood flow may be heavy (trickling out in a stream or fast drips) or light (slowly dripping) and usually stops within 10 minutes.

However, a nosebleed can be more severe, especially in older adults with health conditions such as high blood pressure or taking a blood thinner medicine such as aspirin, warfarin, dabigatran or rivaroxaban.

Common causes of nosebleeds include:

• an injury to your face or a broken nose
• picking your nose using your fingers
• blowing your nose too hard or sneezing
• cold and dry air – this causes the lining of your nose to dry out and crack, eg, during winter
• flying at high altitude
• scuba diving
• an infection in your airway such as a cold or sinusitis.

Other causes of nosebleeds include:

• blood-thinning medicines such as aspirin, warfarin, dabigatran or rivaroxaban (which slow down your blood clotting)
• cocaine use
• overuse of nose sprays
• recent nose surgery
• pregnancy (which causes the blood vessels in your nose to expand)
• a foreign object in your nose – this is more common in children
• a blood disorder such as haemophilia or Von Willebrand's disease
• cancer or a tumour in your nose – this is rare.

High blood pressure can make a nosebleed worse but it is unlikely to be the cause. In children, bleeding may happen for no known reason and is usually not worrying.

You are most at risk of having nose bleeds if you:

• are a young child
• are over 60 years old
• are pregnant
• are on blood-thinning medicines such as aspirin, warfarin, dabigatran or rivaroxaban 
• have a blood disorder such as haemophilia or Von Willebrand's disease.

Nosebleeds are easily recognised by blood dripping from your nose. They may also be felt as a sensation of fluid flowing at the back of your throat.

Most nosebleeds aren't serious and can be usually be treated at home. However, if you have frequent nosebleeds, eg, more than once a week, or very heavy nosebleeds, you should see your doctor. These nosebleeds could be a sign of an underlying bleeding disorder and may lead to complications such as anaemia. If your doctor suspects a more serious problem, they may refer you to an ear, nose and throat (ENT) specialist.

Your doctor will ask you questions about your nosebleed, including whether you have had any injury to your nose, any previous episodes of nosebleeds and whether you are taking any blood-thinning medicines. Your doctor will also examine your nose and look inside your nostrils.

Rarely, more tests may be needed, such as:

• blood tests such as a complete blood count to check your red blood cells, white blood cells and haemoglobin, or a coagulation screen  to find out how fast your blood clots
• nasal endoscopy – a tiny camera on a flexible thin tube used to look closely at the inside of your nose
• a CT scan of your nose.

Most nosebleeds are mild and can be managed easily at home. The aim of treatment is to stop the bleeding and keep your airway open.

Nosebleed first aid at home

If you or someone gets a nosebleed:

1. Reassure them – nosebleeds can be very alarming, especially to young children.
2. Sit upright and lean forward slightly – this will help the blood drain out your nose instead of down your throat.
3. Using your thumb and finger, squeeze the soft part of your nostrils firmly together below the bony bridge for at least 10 minutes or until blood flow has stopped. Young children may need you to do this for them.
4. Breathe through your mouth.
5. Apply a covered icepack to the bridge of your nose – cold helps blood vessels to narrow which slows bleeding.
6. After 10 minutes, check if the bleeding has stopped. If bleeding continues after 20 minutes of pressure or if there is too much bleeding, continue the pressure and see your doctor or call 111 for an ambulance immediately.

Tips for nosebleed first aid

• Make sure you are squeezing the soft part of the nose – it won’t do anything if you are pressing on the hard bony bridge or top part of your nose.
  
• Don't keep releasing the pressure to see if the bleeding has stopped. Stay sitting comfortably and watch the clock for a full 10 minutes before you check.

After a nosebleed avoid these things for at least 24 hours, as they may start the bleeding again:

• picking, sniffing or blowing your nose
• hot food or drinks
• having a hot shower
• strenuous physical activity
• sneezing through your nose (if you have to sneeze, let it go out of your mouth and into your elbow). 

Healthcare treatment for nosebleeds 

A nosebleed may need to be treated by your GP or in a hospital if it is serious or recurrent. Antibiotics cream may be prescribed by your doctor to apply to the inside of your nose.

The following procedures can be done by your GP or in hospital:

• Nasal cautery – this is the use of heat, silver nitrate sticks or electric current to cauterise (burn) and seal the blood vessels causing the problem. This can be done in your GP clinic or a hospital.
• Septal surgery – if the septum (the wall between the nostrils) is crooked it can sometimes cause nosebleeds. If this is the case, your ENT surgeon may recommend having your septum surgically straightened.
• Ligation – this involves very fine surgery to tie off the burst blood vessels. It may be used if other methods don't work.

Do these things to help prevent a nosebleed:

• If you need to blow your nose, do so as gently as possible.
• Don't pick your nose.
• Try vaporisers to keep the air humid or use saline (saltwater) nasal spray if your nose is crusty and dry. These products are available at pharmacies.
• Use a head guard while playing contact sports, such as boxing or rugby.
• Control your blood pressure if you have high blood pressure.
• Talk to your doctor if you are taking blood-thinning medicines and have recurring nosebleeds.
• Avoid overuse of nasal decongestants – always follow packet instructions. Ask your pharmacist if you are unsure.

The following information on epistaxis in adults(external link) is taken from Auckland Regional Healthpathways, NZ, accessed March 2021:

Treatments

• Antibiotic creams and silver nitrate cautery are equally effective.
• Antibiotics – mupirocin cream or fusidic acid cream twice daily in both nostrils for 4 weeks.
• Silver nitrate nasal cautery for recurrent anterior epistaxis (not appropriate for active bleeding). Apply for 1–2 seconds only.

Clinical resources

Nosebleed (epistaxis) – epidemiology, aetiology, diagnosis and management(external link) Patient Info, UK
Epistaxis (nosebleeds)(external link) Fauquierent.net

Continuing professional development

PHARMAC seminar: Ear, nose and throat (ENT) update, 3 of 5. Epistaxis/examination of nasal cavity – Richard Douglas (21 minutes)

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(PHARMAC, NZ, 2019)

For more videos of the same series, visit PHARMAC seminars(external link).