2015, September/October Adirondac Adirondoc
Several factors seem to predispose individuals to nosebleeds, many of which may occur in the backcountry.
Blood always looks copious whenever it gets outside the body and on clothes. That is surely the case with bloody noses. Most bloody noses are self-limited and involve only trivial amounts of blood loss. Yet, they may seem massive and often result in drama. Being familiar with the treatment of simple bloody noses can make one a hero in many settings.
There are two distinct types of nosebleeds. Each results from disruption to the many tiny blood vessels of the nasal cavity and nasal septum, which separates the nostrils. Anterior nosebleeds come from the front of the nose, typically from the part that is made up of “soft bone” or cartilage. By far, these are the commoner, less serious, and usually easiest to treat. Posterior bleeds come from farther back in the nose, in the area more protected by the bones of the face. These are unusual, often occur in individuals with other health problems, and may be very serious. Unfortunately, there is little field first aid for these types of nosebleeds, beyond immediate evacuation to a hospital.
Several factors seem to predispose individuals to nosebleeds, many of which may occur in the backcountry. The breathing of dry air, for example, may make the mucous membranes of the nasal septum more susceptible to injury. Picking the nose is another risk factor, perhaps accounting for most nosebleeds. Frequent sneezing or nose-blowing associated with nasal allergies or colds may also be a predisposing factor. Medications that interfere with blood clotting such as aspirin are also risk factors.
When coming across someone with a nosebleed, the first step should be to size up the situation and ensure that the individual has no other problems and has stable breathing and heart rate. Assuring the individual and others present that the problem is not likely to be serious, and that you know what to do, will go a long way toward deescalating the excitement that is likely to be present. Encourage the individual to sit upright, lean forward so blood does not drip down the throat, and spit any blood that has gone down the throat.
As with any bleeding, the next step is applying direct pressure. In this case, pressure is applied by pinching the end of the nose (soft, fleshy part) tightly between thumb and forefinger. I tell my first aid students that the most important piece of equipment in treating a bloody nose is a watch. At least ten to fifteen minutes of pressure, with no peeking allowed, is mandatory.
If it is easily available in one’s pack, a nasal decongestant such as oxymetazoline (Afrin®) can help by causing the- nasal blood vessels to constrict. I always carry this medication in my backcountry first aid kit.
When the bleeding has stopped, the individual should be encouraged to rest for a while and to avoid bending, straining, or blowing the nose. This will minimize the chance of re-bleeding, a common occurrence. If bleeding begins again, or if simple maneuvers do not stop it, then evacuation from the trek is called for. While planning this, some relief may be obtained by packing a small piece of gauze or tissue into the front of the nose; if it’s available, soaking the packing with the decongestant is also helpful. If packing is used, I recommend leaving it in place until definitive care is available.
~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com. Michael Parker, MD, whom he calls “my favorite otolaryngologist-backpacking partner” reviewed this manuscript and provided helpful suggestions.General First Aid