.* Nosebleeds *
By serger

26 January 2004

With the cold and very dry winter we are having one of my childhood afflictions reoccurred. I’m talking about chronic nosebleeds. The one I just got done with (hopefully) started 8 days ago more or less. I think I finally got it stopped by going to the local Ears, Nose and Throat (ENT) doctor who cauterized it with silver nitrate.(It’s ok, 2 Feb 02).

A little medical disclaimer is in order: I’m not a medical professional. The information I’m relating though based on sound medical principles is not presented to be a regimen of treatment. It is a discussion on what I’ve done to stop moderate to severe nosebleeds that were both acute and chronic in their nature with no additional trauma. If you are acting as a caregiver, be aware of body fluid transfer protocols and protect yourself. We’re talking about bleeding, sometimes lots of it after all. Any action you take after reading this discussion should be done after consultation with your medical professional and done with their concurrence. I take no responsibility for your actions.

This article is for those of you who have never had a severe nosebleed. It details what I had to do as it progressed to allow you to stop one if need be by your self. And if you can’t stop it you’ll know what happens when you end up in the Emergency Room or the ENT’soffice.

First of all, a little basic anatomy which you probably know, or not. The nasal cavity is full of capillaries that moderate the temperature of the air you breath to help maintain the temperature of your skull and to minimize the shock of very hot or cold air on the lungs. It also acts as a humidifier to moderate the effect of dry air as well as a dust filter. These capillaries are all very close to the surface. Since they are so shallow it is easy to open one up for whatever reason. When this happens you have a nosebleed.

The usual causes of nosebleeds are as follows:

Mechanical insertion. Putting something in the nose, (like a finger) and subsequent abrasion of the nasal wall, usually on the septum side.

Mechanical shock. Getting smacked in the head or the concussion from explosions as an example.

Environmental impacts. Dry air, followed by dust and sand, which dry out and/or abrade the nasal wall. Young children are readily susceptible to heat related bleeds from being out in the sun and their poor little systems trying to cope with the heat and losing.

Severe coughing or sneezing that causes a spike in blood pressure and subsequent bleeds.

High blood pressure and arteriosclerosis (hardening of the arteries), which cause failures of the capillary walls.

Prescription drug interaction. Certain drugs such as anticoagulants or blood thinners like Coumadin, vasodilators like Minoxidil, and over the counter analgesics such as aspirin and ibuprophen (Motrin) can cause bleeds or exacerbate (make worse) any bleeding tendencies.

Illegal drug interaction. Nasal ingestion (snorting) of such drugs as powder cocaine and methamphetamine cause rapid effects in the user due to the thin skin of the nose and the ease of ingestion via that route. Chronic abusers are known in ER’s by the sad state of their noses and the frequency of the bleeds they encounter. There are also incidences of abusers over dosing and drowning or bleeding out in a nosebleed if no intervention occurs.

To stop most simple bleeds the process is as follows:

1. Place the bleeder in a sitting position. Loosen any restrictive clothing and keep the bleeder cool. Place in the shade if necessary.
2. Make a roll of tissue paper (paper towel works well) about half the diameter of a cigarette, slightly less than 7mm or ¼ of an inch and about an inch long or 30mm.
3. Moisten this roll and place it under the upper lip and press on the skin under the nose.
4. Continue pressing on the lip until the bleed stops.

This is the easiest case to deal with in my experience. It is also the way just about everyone I know who has had a simple bleed has been told how to deal with it.

If the bleed continues, the next step is to place a cold moist towel on the back of the neck as well as the steps listed above.

The ENT told me the mechanism here is the bodies reflex to try and maintain temperature to the skull. Since the nasal area is not unusually hot or cold and the back of the neck is sending a cold request the body obliges by diverting blood in the skull to the back of the neck. To do this it restricts blood flow to other areas of the skull and shunts it to the cold area. This reduced flow causes the bleeding to be reduced and the clotting to be facilitated.

If this doesn’t work the next step in intervention is to further reduce blood availability by shutting down another arterial path.

What you do is to take the hand that is not pressing on the lip and place your index finger and thumb across the bridge of the nose where the bone transitions to cartilage and press firmly on both sides of the nose toward the skull without restricting any of the air passages. Air contact with blood enhances clotting and in this case that’s what you want.

One thing you need to remember is this treatment is progressive to minimize stress in the nasal cavity and you want to achieve bleeding cessation with the minimal amount of screwing around with the skull. The ENT said less is better. And what he meant was, "Do thy patient no harm". Depending on the person bleeding you want the minimum of stress on them to get the bleeding to stop. Like he said," You don’t apply a tourniquet on the neck because the nose is leaking". He also noted you want to stop the bleed as fast as possible because of other complications. He didn’t elaborate but I think one of the things he was talking about was blood loss and what that can lead to.

Hopefully at this point you have gotten control of the bleeding and you are getting the clot you need to stop the bleed.

If not you might have a problem.

The rule of thumb on this stuff from "them that know" is if you cannot get the bleed to stop after an hour (some say a half hour) seek medical help.

In my case I was stubborn enough I waited for 5 hours of continuous bleeding with minor and ineffective clotting prior to going to the Emergency Room. (I mean after all it’s just a nose bleed right?) When I got there I went to the head of the line. I’m pretty sure, but not positive, in the ER triage world if someone comes in who is bleeding uncontrollably they get preferential treatment over someone who has a bad cough. Any way I went to the head trauma exam room. They let me bleed a while and then the ER Doctor put a nasal speculum up my nose, so he could see what he was doing, and with a silver nitrate swab cauterized my nose. I was required to wait a half hour to make sure I’d stopped leaking. From my description of the duration of this bleed (6 days off and on) the ER doc estimated I lost 3 cups (900ml) or more of blood. They sent me home after the paperwork was done.

Two days later I went outside with the dog. The cold air hit my nose. The cauterization failed and blood gushed like water pouring out of a glass. I thought, "Great here we go again." I did all the easy tricks for an hour to get it to stop with no luck. At that point I decided to get to the ENT’s office. He was an ear, NOSE, and throat doctor after all and he should know how to stop a nosebleed. I was at a minimum a half-hour from his office in good weather but with the icy roads I needed the extra wiggle room. I figured 50 minutes.

Many people place tissue up their noses to get the clot they need and for some of them it sort of works. In my case all the tissue would do is to act as a wick and facilitate the bleeding. Besides, I needed both hands to drive even if/when it failed. I couldn’t do the "press on the nose" thing.

So I performed a medical procedure on myself.

What I did was to take about a 1-foot (300mm) section of 2-inch (50mm) roller gauze, coat it with a medical grade emollient (glorified petroleum jelly with vitamin A and D added) and cram it up my nose with a 4-inch Kelly forceps. I would have used smaller gauze but I didn’t have any. At that point I was stable enough to drive.

I then made a beeline to the ENT’s office. When I got here I went to the head of the line again. I was placed in an exam room and while waiting I filled out the paperwork. The ENT cauterized my nose again. But this time he did it with a little ENT trick. It seems with a nose bleed like I had to cauterize the capillary you need to cut it in two and apply cautery to the two ends. There are enough blood sources in the nose this is not a problem and you don’t have to worry about the tissue you deprived of a blood source from dying. (Becoming necrotic in Medicaleze).

As he waited to make sure the procedure was completed successfully we talked a little and that’s where I got his input for this article. He also wanted to know where I got my medical training (I pack a mean nose) and when I told him it turned out we were both at the same military hospital at the same time 20 years ago. He was a surgeon and I was a biomedical equipment technician there. Small world we run in.

1.The more medical knowledge you have to make sound decisions the better off you and yours will be. Get training and the vocabulary you need. You need the training so you know what to do to stop the bad thing from happening. You need the vocabulary to tell those who may have to bail you out what happened and what you did. They tend to react better and quicker if you don’t just point and grunt.

2.Don’t wait to get medical help if you can’t stop the bad thing from happening. That’s why they are there. In a post event situation that’s where the best medical training you have might be marginal. See Item 1 above.

3.Have the medical equipment and supplies on hand you need to perform the procedures you need to perform. And here’s another thing to think about. You might want to have medical equipment and supplies that are beyond your level of training on hand in the event we have a real problem in the future. If you have them then you might be able to have someone who knows their usage use them to help you. And they might be useful barter items.

4.Don’t get rattled. Be cool and methodical about what you do. You can do yourself harm if you don’t. On my trip to the ER I was scared and my blood pressure showed it. I was rattled and shouldn’t have driven myself while holding onto the bridge of my nose and bleeding down my jacket. I was not helping myself and had almost gotten "shocky" by the time I got treated. My blood pressure (BP) was 210/121 and they thought that’s why I was bleeding (not). But I do admit having the BP going through the ceiling didn’t help. For the record I usually run 140/75.

5.After the serger nosebleed show was over I did some research on the gear ER’s use for this type of situation. I found a company in Colorado USA that deals a lot with Rhino (nose) instruments and dressings. They also seem to do a lot with cosmetic surgery. Anyway they have a device called the Rhino Rocket. It is a gel sponge system used like nose packing but is quicker acting because there is no packing time. Our ER uses it. You just slide the rocket up the nose and deploy it. The fluid the patient is leaking causes the sponge dressing to expand up to 6 times the normal dry size and you have no more bleed. That might be a thing to have in the trauma kit for your medic to have at the base camp. You might also want a nasal speculum, a pack of silver nitrate swabs and head mounted flashlight to allow the medic to stop a bad bleed. The other option might just be the yard of gauze up the nose and the fun you have when it gets removed. Of course it is preferable to bleeding out.

Here’s the link to their site (the Rhino Rocket folks). They also sell nasal speculums. :

http://www.shippertmedical.com/Merchant2/merchant.mvc?Screen=PROD&Store_Code=SMT&Product_Code=11S-S-08AS&Category_Code=RHIROK

Here’s a link to silver nitrate cautery applicators:

http://store.devinemedical.us/silnitaptub1.html

Thanks for the read.

serger