Karen Shapiro, PharmD, BCPS

Disclosures

December 06, 2005

Question

Can you advise on the emergency treatment of nosebleeds? This may seem trivial, but patients on warfarin therapy may have a real emergency when surgical intervention is unavailable. Are there any new successful treatments?

Response from Karen Shapiro, PharmD, BCPS

I do not know of any new successful treatments for nosebleeds (epistaxis), but sometimes the old standby remedies of pinching the nose, elevating the head, and applying ice are enough. If not, try the additional measures described below.

For patients on anticoagulant therapy, it is important to recognize that the risk of bleeding increases as the international normalized ratio (INR) increases. If a nosebleed occurs, check the INR. Discontinue anticoagulants if necessary. Consider the use of vitamin K, but do not use it unless truly indicated. Unnecessary or inappropriate vitamin K use can make it difficult to return the person to a therapeutic INR. In fact, minor bleeding may not be due to an elevated INR. Some people have a predisposition to nosebleeds, which could be due to allergies or minor trauma, the inappropriate application of nasal steroids, or use of cocaine or excessive alcohol.

To attempt to stop a bleed, pinch the soft lower part of the patient's nose and press toward the face. (The head must be positioned higher than the heart.) Hold for at least 5 minutes. It is helpful to apply crushed ice in a bag or towel to the nose and cheeks. Counsel the patient not to blow his or her nose afterwards and to refrain from smoking. Ask the patient if he or she is taking aspirin, clopidogrel, or other agents that increase bleeding risk. In elderly patients on warfarin, these agents might include natural products such as ginkgo biloba, high doses of vitamin E (which are likely not indicated), or high doses of garlic.

If bleeding continues after several minutes, the treatment recommendation depends on whether it is an anterior or posterior bleed. Most nosebleeds are anterior and are caused by a superficial blood vessel. Treatment includes topical vasoconstrictors to constrict the blood vessels and cauterization to stop the bleeding.[1,2] Topical vasoconstrictors used for nasal congestion can be tried in any practice setting.

For posterior nosebleeds, anterior-posterior (AP) nose packs are used to apply pressure to the bleeding site. These are commercial or clinician-made devices that swell to compress the site. These patients (and anterior bleed patients with recurrent episodes) should be referred to an ear-nose-throat physician.

Following a recurrent or significant nosebleed, it is helpful to place a small cotton plug saturated in antibacterial ointment in the anterior nasal chamber. This will reduce airflow and allow the damaged mucosa to heal.

Nosebleeds can occur more frequently when the membranes become dry from heated air during the winter months or in climates with low humidity. In these cases, patients can use a saline nasal spray or Vaseline or A&D ointment to help keep the membranes moist.

Although not recommended in any guideline, case reports have described patients with recurrent nosebleeds who find relief from applying topical estrogen cream 2-3 times daily.[3] This may help thicken the nasal mucosa. Clinicians recommend either Premarin cream or compounded products.

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