Bleeding from the nose, referred to as epistaxis by doctors, is a rather common phenomenon. This flows from the fact that the nose has a very good blood supply, but cannot be helped much by the nose's prominent position or the fact that many individuals take it upon themselves to manually excavate it.

The Basics

Most people know where the nose is, but it's the insides that count when talking about nose bleeds. Branches of both the internal and external carotid arteries supply the nose. An important landmark is Little's area, also known as Keisselbach's plexus, where the ends of several of the arteries supplying the nose meet and anastomose¹. Little's area is a common site for bleeds, being situated towards the front of each nostril on the nasal septum². Bleeding from the lateral walls occurs less often but is trickier to control, as are nose bleeds in elderly individuals.

Causes

While nosebleeds can occur spontaneously, they are often due to damage to the vessels through trauma such as vigorous and frequent removal of dried mucus from inside the nostrils³ or a blow to the face⁴. High blood pressure, anti-clotting agents and bleeding disorders increase the risk of nasal bleeding, as do nasal allergies such as hay fever. Other factors affecting the likelihood of bleeding include the humidity, as dry air⁵ tends to cause the nostrils to become inflamed.

First Aid

... Or, 'It's ruining my shirt! How do I make it stop?!'⁶

1. Don't panic.

2. Remove patient to an appropriate environment.

If your nose starts to bleed, let someone else know about it even if you intend to treat it yourself. The first step is to remove the bleeder to a bathroom or similar place with a good supply of water and paper towels; note though that if the bleed is torrential or persists for more than 15 minutes then medical attention should be sought. Steps should be taken to protect clothing if necessary.

3. Apply pressure over the lower part of the nose for 10 minutes.

Apply steady pressure with a finger and thumb across the fleshy part of both nostrils just below the bone for around 10 minutes. Squeezing the nose in this manner will stop most bleeds originating from Little's area. Note that squeezing over the bony upper part of the nose will not stop the bleeding. In the meantime, the bleeder should breathe through their mouth, try not to swallow⁷, and lean forward to prevent the blood from running back through the nose and into their airway. If necessary, use a tissue or cotton wool ball in the entrance of the nostril, but do not be tempted to place anything any further inside the nostril. An ice pack wrapped in a towel may be temporarily applied to the bridge of the nose but should not replace pinching the nose.

4. If bleeding persists for more than 15 minutes, seek urgent medical attention.

If the bleeding stops, the patient should remain still for a short while and avoid any actions that might restart the bleeding. Nose blowing and picking should be avoided for the rest of the day. After a severe nose bleed it is best to avoid nose blowing and picking, smoking, strenuous activities, very hot drinks, trauma to the nose and sneezing through the nose where possible for the next seven days.

Medical Treatment

If the site of bleeding is clear, persistent nosebleeds can be controlled by cauterising the offending blood vessel with a silver nitrate stick, having first applied a plug of dressing soaked in local anaesthetic⁸ and a vasoconstrictant⁹. Another approach is to pack the nose with specially-shaped gauze that is placed in the nose in loops so that the nostril is evenly packed throughout. In cases of severe bleeding a post-nasal pack can be introduced using a general anaesthetic - this is a specialist technique, and also requires specialist care as these packs can cause airway obstruction. Nasal tampons also exist¹⁰, and specially-designed balloons can be inflated inside the nose, with different varieties being used depending on whether the site of the bleed is at the front or the back of the nose.

Patients with severe enough bleeding to require packing are admitted to hospital for observation and are checked for high blood pressure. Intravenous fluids and blood may need to be given depending on the amount of blood lost. If bleeding persists after medical treatment, surgery may be required to electrically cauterise the source or tie off either the artery supplying the bleed or, rarely, the external carotid.

Folk Remedies

Many other treatments for nosebleeds have been suggested in the past, ranging from placing blotting paper under the tongue or drinking water with pepper in it, to sniffing cobwebs or placing a key down the back of the neck. One old 'cure' actually involves tying a cord around the sufferers neck - presumably this works by stopping the flow of blood to their head, and is thus inadvisable to say the least.

Repeated Bleeding

Repeated attacks most often occur in children (little bleeders), where the cause may well be excessive nose-picking. The simple approach of stopping the picking may be enough, but in those with spontaneous bleeds a small amount of petroleum jelly can be used to prevent the nose from drying out, becoming inflamed and bleeding. If bleeding still continues to occur, it's a good idea to go and see your doctor.

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¹ Join together.
² The wall between the two nostrils.
³ Often referred to as 'nose picking'.
⁴ Such as a high-force impact with a football or an elephant's trunk.
⁵ Such as in the cabin of an airliner or Las Vegas, Nevada, USA.
⁶ A study in Leeds in 1998 found that only 11% of the population knew to squeeze the lower part of their nose to stop a nose bleed.
⁷ If necessary they should spit into a sink or bowl instead.
⁸ A drug that causes localised numbness, thus preventing the sensation of pain from a small area.
⁹ A drug that causes blood vessels to contract, thus reducing blood flow within the vessels.
¹⁰ Note that these are nasal tampons - don't get any funny ideas.