Nosebleed
Office Hours Telehealth Triage Protocols | Adult | 2023
⦁ Bleeding from 1 or both nostrils
⦁ Not due to a traumatic injury
⦁ Includes follow-up calls about nasal packing placed by health care providers to control bleeding
TRIAGE ASSESSMENT QUESTIONS
DEFINITION
Call EMS 911 Now
Fainted (passed out), or too weak to stand following large blood loss
R/O: impending shock. FIRST AID: Lie down with the feet elevated.
Sounds like a life-threatening emergency to the triager
See More Appropriate Protocol
Nosebleed followed nose injury
Go to Protocol: Nose Injury (Adult)
Go to ED/UCC Now (or to Office With PCP Approval)
Bleeding present > 30 minutes and using correct method of direct pressure
R/O: posterior nosebleed, coagulopathy
Bleeding now and second call after being instructed in correct technique of direct pressure
R/O: posterior nosebleed, coagulopathy
Lightheadedness or dizziness
R/O: excessive blood loss
Pale skin (pallor) of new-onset or worsening
R/O: excessive blood loss
Has nasal packing (inserted by health care provider to control bleeding) and now has new rash
R/O: Toxic Shock Syndrome
Has nasal packing and now has bleeding around the packing (Exception: Few drops or ooze.)
Reason: May need to be re-packed or have nasal cautery.
Patient sounds very sick or weak to the triager
Reason: Severe acute illness or serious complication suspected.
Go to Office Now
Large amount of blood has been lost (e.g., one cup)
R/O: anemia
See in Office Today
Bleeding recurs 3 or more times in 24 hours despite direct pressure
Taking Coumadin (warfarin) or other strong blood thinner, or known bleeding disorder (e.g.,
thrombocytopenia)
Reason: Higher risk of serious bleeding; may need testing of INR, ProTime, or platelet count. Note: Besides
Coumadin, other strong blood thinners include Arixtra (fondaparinux), Eliquis (apixaban), Pradaxa
(dabigatran), Xarelto (rivaroxaban), and heparins (e.g., Lovenox, Fragmin, Innohep).
Has skin bruises or bleeding gums that are not caused by an injury
R/O: bleeding disorder
Has nasal packing and now has fever > 100.4° F (38.0° C)
R/O: sinusitis
Patient wants to be seen
See in Office Within 3 Days
Has nasal packing (inserted by health care provider to control bleeding)
Reason: Nasal packing needs removal 2 to 3 days after placement.
See in Office Within 2 Weeks
Hard-to-stop nosebleeds are a chronic symptom (recurrent or ongoing AND lasting > 4 weeks)
R/O: bleeding disorder
Easy bleeding present in other family members
Home Care
Mild-moderate nosebleed and bleeding has stopped now
Bleeding present < 30 minutes and using correct method of direct pressure
Nosebleed and needs instruction in correct technique of applying direct pressure
Home Care Advice for Mild Nosebleed
Reassurance and Education - Nosebleed:
⦁ Nosebleeds are common.
⦁ It sounds like a routine nosebleed that we can treat at home.
⦁ You should be able to stop the bleeding if you use the correct technique.
⦁ Here is some care advice that should help.
1.
Pinch the Nostrils to Stop a Nosebleed:
⦁ First gently blow the nose to clear out any large clots.
⦁ Lean Forward: Sit down and lean forward. Reason: Blood makes people choke if they lean
backwards.
⦁ Pinch the Nose: Gently squeeze the soft parts of the lower nose (nostrils) together. Use your
thumb and your index finger in a pinching manner. Do this for 15 minutes. Use a clock or watch
to measure the time. Goal: Apply constant pressure to the bleeding point.
⦁ If the bleeding continues after 15 minutes of squeezing, move your point of pressure and
2.
repeat again for another 15 minutes.
Nasal Decongestant Spray for a Nosebleed:
⦁ If pinching the nostrils does not stop the bleeding, you can try a nasal decongestant nose
spray.
⦁ Use either oxymetazoline (Afrin in U.S; Drixoral in Canada) or phenylephrine (Neo-
Synephrine). You can get them over-the-counter at the drugstore.
⦁ Method 1: Blow the nose to clear out any clots. Spray two times into the nostril that is bleeding.
Pinch the nostrils together again for 10 to 15 minutes. The spray shrinks the blood vessels and
helps stop bleeding.
⦁ Method 2: Blow the nose to clear out any clots. Put a piece of gauze wet with decongestant
spray in the bleeding nostril. The gauze helps to apply pressure and the spray shrinks the blood
vessels. Pinch the nostrils together again for 10 to 15 minutes.
3.
Nasal Decongestants - Extra Notes and Warnings:
⦁ Do not use these medicines if you have high blood pressure, heart disease, prostate problems,
or an overactive thyroid.
⦁ Do not use these medicines if you are pregnant.
⦁ Do not use these medicines if you have used a MAO inhibitor such as isocarboxazid
(Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or
tranylcypromine (Parnate) in the past 2 weeks. Life-threatening side effects can occur.
⦁ Do not use these medicines for more than 3 days. Reason: Rebound nasal congestion when
you stop taking them.
⦁ Before using any medicine, read all the instructions on the package.
4.
Expected Course:
⦁ Over 99% of nosebleeds will stop following 15 minutes of direct pressure if you press on the
right spot.
⦁ After swallowing blood from a nosebleed, you may feel nauseated because the blood can
irritate your stomach. You may also later pass a dark stool that contains the blood.
5.
Call Back If:
⦁ Nosebleed lasts longer than 30 minutes with using direct pressure
⦁ Lightheadedness or weakness occurs
⦁ Nosebleeds become worse
⦁ You become worse
6.
Reassurance and Education - Nosebleeds During Pregnancy:
⦁ Nosebleeds happen more often during pregnancy.
⦁ They can re-bleed if you rub your nose or blow the nose too hard.
⦁ You should be able to stop the bleeding if you use the correct technique.
⦁ Here is some care advice that should help.
1.
Pinch the Nostrils to Stop a Nosebleed:
⦁ First gently blow the nose to clear out any large clots.
⦁ Lean Forward: Sit down and lean forward. Reason: Blood makes people choke if they lean
backwards.
⦁ Pinch the Nose: Gently squeeze the soft parts of the lower nose (nostrils) together. Use your
thumb and your index finger in a pinching manner. Do this for 15 minutes. Use a clock or watch
to measure the time. Goal: Apply constant pressure to the bleeding point.
⦁ If the bleeding continues after 15 minutes of squeezing, move your point of pressure and
repeat again for another 15 minutes.
2.
Expected Course:
⦁ Over 99% of nosebleeds will stop following 15 minutes of direct pressure if you press on the
right spot.
3.
Key Points
⦁ Most nosebleeds are from the anterior nasal septum.
⦁ Most nosebleeds will stop with correctly applied pressure over the bleeding area. The correct
method is to squeeze the soft parts of the nose using thumb and index finger, thus applying pressure
to the anterior nasal septum. Hold for 10 to 15 minutes.
⦁ The leading causes of nosebleeds are dry air, upper respiratory infections (URIs), and nose picking.
⦁ The medical term for nosebleed is epistaxis.
Causes
Common causes of nosebleeds are:
⦁ Dry air
⦁ Nose injury
⦁ Nose picking
⦁ Upper respiratory infections (URIs), too vigorous nose blowing
Less common causes include:
BACKGROUND INFORMATION
FIRST AID Advice for Nosebleed:
⦁ First blow the nose to clear out any large blood clots.
⦁ Placing your thumb and index finger over each side of the soft lower portion of the nose, firmly
pinch the nostrils together. Pinch the nostrils together for 10-15 minutes.
⦁ Lean slightly forward. This keeps the blood from trickling down the back of your throat.
FIRST AID
⦁ After swallowing blood from a nosebleed, you may feel nauseated because the blood can
irritate your stomach. You may also pass a dark stool tomorrow.
Call Back If:
⦁ Nose bleeding lasts longer than 30 minutes with using direct pressure
⦁ Lightheadedness or weakness occurs
⦁ Nosebleeds become worse
⦁ You become worse
4.
Preventing Future Nosebleeds:
⦁ Dry air in your house or workplace can increase the chance of nosebleeds occurring. If the air
is dry, use a humidifier in your bedroom to keep the nose from drying out. You can also apply
petroleum jelly to the center wall (septum) inside the nose twice daily to reduce cracking and to
promote healing.
⦁ Bleeding can start again if you rub your nose or blow the nose too hard. Avoid touching your
nose and nose picking. Avoid blowing the nose.
⦁ Do not take aspirin or other anti-inflammatory medications (e.g., ibuprofen, Advil, Motrin,
Aleve), unless you have been instructed to by your doctor (or NP/PA).
1.
Call Back If:
⦁ You have more questions
2.
⦁ Bleeding disorders (e.g., hemophilia, Von Willebrand disease)
⦁ Nasal drug inhalation (e.g., cocaine)
⦁ Nasal foreign body
⦁ Nasal tumors
⦁ Septal deviation
Risk Factors
Nosebleeds are more common and sometimes more difficult to treat in older adults. A typical adult
caller with a nosebleed might be 72 years old, hypertensive, and exposed to the dry air of winter.
Other risk factors for a nosebleed are:
⦁ Atherosclerosis
⦁ Blood thinner medicines: Certain medicines can increase the risk of bleeding. These include:
aspirin, NSAID's (e.g., ibuprofen, naproxen), heparin, coumadin, and Plavix (clopidogrel). Other
strong blood thinners are: Arixtra (fondaparinux), Eliquis (apixaban), Pradaxa (dabigatran), and
Xarelto (rivaroxaban).
⦁ Hypertension
⦁ Pregnancy: Nosebleeds happen more often during pregnancy.
Types
There are two main types of nosebleeds, based on their location inside the nose.
⦁ Anterior: Most nosebleeds (95%) are from the anterior part of the nose. This is the part of the nose
that can easily be seen by a doctor (or NP/PA) using a standard rhinoscope or light.
⦁ Posterior: About 5% of nosebleeds are inside the posterior part of the nose. These cannot be easily
seen by a doctor using a standard rhinoscope or light. These occur more often in older people and
are more difficult to treat. These patients more often need nasal packing and more often get admitted
to the hospital.
Treatment
Most nosebleeds can be managed at home with nasal compression (pinching the nostrils). Here are
the instructions for performing this first aid care.
⦁ First gently blow the nose to clear out any large clots.
⦁ Lean Forward: Sit down and lean forward. Reason: Blood makes people choke if they lean
backwards.
⦁ Pinch the Nose: Gently squeeze the soft parts of the lower nose (nostrils) together. Use the thumb
and index finger in a pinching manner. Do this for 15 minutes. Use a clock or watch to measure the
time. Goal: Apply constant pressure to the bleeding point.
⦁ If the bleeding continues after 15 minutes of squeezing, move your point of pressure and repeat
again for another 15 minutes.
If the bleeding does not stop after correctly applied nasal compression, then the person will probably
need to go an urgent care center or emergency department. There are several treatments that a
doctor (or NP/PA) can perform depending on the location and severity of the bleeding.
⦁ Anterior or posterior nasal packing
⦁ Cautery (e.g., silver nitrate)
⦁ Topical anesthetics and topical vasoconstrictor medicines
REFERENCES
1. Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. 2008 Jun;41(3):525-36.
2. Khan M, Conroy K, Ubayasiri K, Constable J, Smith ME, Williams RJ, Kuhn I, Smith M, Philpott
C. Initial assessment in the management of adult epistaxis: systematic review. J Laryngol Otol.
2017 Dec;131(12):1035-1055.
3. Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005 Jan 15;71(2):305-11.
4. Pantanowitz L. Epistaxis in the older hypertensive patient [letter]. J Am Geriatr Soc.
1999;47(5):631.
5. Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children.
Cochrane Database Syst Rev. 2012 Sep 12;(9):CD004461.
6. Schlosser RJ. Epistaxis. N Engl J Med. 2009 Feb 19;360(8):784-9.
7. Tan LK. Epistaxis. Med Clin North Am. 1999;83(1):43-56.
8. Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, et.al. Clinical
Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020
Jan;162(1_suppl):S1-S38.
9. Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, et.al. Clinical
Practice Guideline: Nosebleed (Epistaxis) Executive Summary. Otolaryngol Head Neck Surg.
2020 Jan;162(1):8-25.
10. Womack JP, Kropa J, Jimenez Stabile M. Epistaxis: Outpatient Management. Am Fam
Physician. 2018 Aug 15;98(4):240-245.
Author:
David A. Thompson, MD, FACEP
Content Set:
Office Hours Telehealth Triage Protocols | Adult
Last Revised:
5/24/2023
Version Year:
2023
AUTHOR AND COPYRIGHT
Last Reviewed:
3/10/2023
2000-2023, LaGrange Medical Software, Inc.. All rights reserved.
Copyright:
Schmitt-Thompson Clinical Content
Company: