Editing Nosebleed (section)

== Treatment ==
Most anterior nosebleeds can be stopped by applying [[Emergency bleeding control|direct pressure]], which helps by promoting blood [[coagulation|clots]].<ref name=Kell2014 /> Those who have a nosebleed should first attempt to blow out any blood [[coagulation|clots]] and then apply pressure to the soft anterior part of the nose (by pinching the [[Human nose|nasal ala]]; not the bony [[nasal bridge]]) for at least five minutes and up to 30 minutes.<ref name=Kell2014 /> Pressure should be firm and tilting the head forward helps decrease the chance of nausea and airway obstruction due to blood dripping into the airway.<ref name="AAFP" /> When attempting to stop a nosebleed at home, the head should not be tilted back.<ref name=AFP2005 /> Swallowing excess blood can irritate the stomach and cause vomiting. [[Vasoconstriction|Vasoconstrictive]] medications such as [[oxymetazoline]] (Afrin) or [[phenylephrine]] are widely available over the counter for treatment of [[allergic rhinitis]] and may also be used to control benign cases of epistaxis.<ref name="pmid2676467">{{cite journal|vauthors=Guarisco JL, Graham HD|year=1989|title=Epistaxis in children: causes, diagnosis, and treatment|journal=Ear Nose Throat J|volume=68|issue=7|pages=522, 528–30, 532 passim|pmid=2676467}}</ref> For example, a few sprays of [[oxymetazoline]] may be applied into the bleeding side(s) of the nose followed by application of direct pressure. Those with nosebleeds that last longer than 30 minutes (despite use of direct pressure and vasoconstrictive medications such as [[oxymetazoline]]) should seek medical attention.<ref name=Kell2014 />

{{Gallery
| title        = Clip used to stop a nosebleed
| width=220
| height=250
| File:NasalClip.jpg|
| File:NasalPressureAP.jpg|
| File:NasalPressureL.jpg|
}}

=== Chemical cauterization ===
This method involves applying a chemical such as [[silver nitrate]] to the nasal mucosa, which burns and seals off the bleeding.<ref name=":1" /> Eventually the nasal tissue to which the chemical is applied will undergo [[necrosis]].<ref name=":1" /> This form of treatment is best for mild bleeds, especially in children, that are clearly visible.<ref name=":1" /> A topical anesthetic (such as [[lidocaine]]) is usually applied prior to cauterization. Silver nitrate can cause blackening of the skin due to silver sulfide deposit, though this will fade with time.<ref>{{Cite journal |last1=Béquignon |first1=E. |last2=Teissier |first2=N. |last3=Gauthier |first3=A. |last4=Brugel |first4=L. |last5=Kermadec |first5=H. De |last6=Coste |first6=A. |last7=Prulière-Escabasse |first7=V. |date=2017-08-01 |title=Emergency Department care of childhood epistaxis |url=https://emj.bmj.com/content/34/8/543 |journal=Emerg Med J |volume=34 |issue=8 |pages=543–548 |doi=10.1136/emermed-2015-205528 |issn=1472-0205 |pmid=27542804 |s2cid=4041588|url-access=subscription }}</ref> Once the [[silver nitrate]] is deposited, [[Saline (medicine)|saline]] may be used to neutralize any excess [[silver nitrate]] via formation of [[silver chloride]] precipitate.

=== Nasal packing ===
If pressure and chemical cauterization cannot stop bleeding, nasal packing is the mainstay of treatment.<ref name=":2">{{Cite journal|last1=Iqbal|first1=I. Z.|last2=Jones|first2=G. H.|last3=Dawe|first3=N.|last4=Mamais|first4=C.|last5=Smith|first5=M. E.|last6=Williams|first6=R. J.|last7=Kuhn|first7=I.|last8=Carrie|first8=S.|date=December 2017|title=Intranasal packs and haemostatic agents for the management of adult epistaxis: systematic review|journal=The Journal of Laryngology & Otology|volume=131|issue=12|pages=1065–1092|doi=10.1017/S0022215117002055|pmid=29280695|s2cid=37082577|issn=0022-2151}}</ref> Nasal packing is typically categorized into anterior nasal packing and posterior nasal packing.<ref name="Kill2014">{{cite journal|last=Killick|first=N|author2=Malik, V|author3=Nirmal Kumar, B|date=Mar 2014|title=Nasal packing for epistaxis: an evidence-based review.|journal=British Journal of Hospital Medicine|volume=75|issue=3|pages=143–7|doi=10.12968/hmed.2014.75.3.143|pmid=24621629}}</ref> Nasal packing may also be categorized into dissolvable and non-dissolvable types.

Dissolvable nasal packing materials stop bleeding through use of thrombotic agents that promote blood clots, such as [[surgicel]] and [[gelfoam]].<ref name="Kell2014" /> The thrombogenic foams and gels do not require removal and dissolve after a few days. Typically, dissolvable nasal packing is first attempted; if the bleeding persists, non-dissolvable nasal packing is the next option.

Traditionally, nasal packing was accomplished by packing gauze into the nose, thereby placing pressure on the vessels in the nose and stopping the bleeding. Traditional gauze packing has been replaced with other non-dissolvable nasal packing products such as [[Polyvinyl alcohol|Merocel]] and the Rapid Rhino.<ref name=":2" /> The Merocel nasal tampon is similar to gauze packing except it is a synthetic foam polymer (made of polyvinyl alcohol and expands in the nose after application of water) that provides a less hospitable medium for bacteria.<ref name="Kell2014" /> The Rapid Rhino stops nosebleeds using a balloon catheter, made of [[Carboxymethyl cellulose|carboxymethylcellulose]], which has a cuff that is inflated by air to stop bleeding through extra pressure in the nasal cavity.<ref name=":2" /> Systematic review articles have demonstrated that the efficacy in stopping nosebleeds is similar between the Rapid Rhino and [[Merocel]] packs; however, the Rapid Rhino has been shown to have greater ease of insertion and reduced discomfort.<ref name=":2" /> Posterior nasal packing can be achieved by using a [[Foley catheter]], blowing up the balloon when it is in the back of the throat, and applying anterior traction so that the inflated balloon occludes the [[choana]]e.<ref name="Kill2014" /> Patients who receive non-dissolvable nasal packing need to return to a medical professional in 24–72 hours in order to have packing removed.<ref name="Kell2014" /><ref name="Stat2019" /> Complications of non-dissolvable nasal packing include [[abscess]]es, [[Nasal septal hematoma|septal hematomas]], [[sinusitis]], and pressure necrosis.<ref name="AFP2005" /> In rare cases [[toxic shock syndrome]] can occur with prolonged nasal packing. As a result, any patient who has non-dissolvable nasal packing should be given prophylactic antibiotic medication to be taken as long as the nasal packing remains in the nose.<ref name="AFP2005" />

===Surgery===
Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anesthesia to identify an elusive bleeding point or to directly ligate (tie off) the blood vessels supplying the nose. These blood vessels include the [[sphenopalatine artery|sphenopalatine]], anterior and posterior ethmoidal arteries. More rarely the maxillary or a branch of the external [[Common carotid artery|carotid artery]] can be ligated. The bleeding can also be stopped by intra-arterial [[embolization]] using a catheter placed in the groin and threaded up the aorta to the bleeding vessel by an [[Interventional radiology|interventional radiologist]].<ref name="NIH" /> There is no difference in outcomes between embolization and ligation as treatment options, but embolization is considerably more expensive.<ref>{{cite journal|last=Villwock|first=JA|author2=Jones, K |title=Recent trends in epistaxis management in the United States: 2008–2010.|journal=JAMA Otolaryngology–Head & Neck Surgery|date=Dec 2013|volume=139|issue=12|pages=1279–84|pmid=24136624|doi=10.1001/jamaoto.2013.5220|doi-access=}}</ref> Continued bleeding may be an indication of more serious underlying conditions.<ref name="NIH">[https://www.nlm.nih.gov/medlineplus/ency/article/003106.htm MedlinePlus Medical Encyclopedia: Nosebleed] U.S. [[National Library of Medicine]] [[Medline Plus]] service. Retrieved 2010-03-15.</ref>

=== Tranexamic acid ===
[[Tranexamic acid]] helps promote blood clotting.<ref name="Jos2018" /> For nosebleeds it can be applied to the site of bleeding, taken by mouth, or injected into a vein.<ref name="Jos2018" />

=== Other ===
The utility of local cooling of the head and neck is controversial.<ref>{{cite journal|last=Folz|first=BJ|author2=Kanne, M |author3=Werner, JA |title=[Current aspects in epistaxis].|journal=HNO|date=November 2008|volume=56|issue=11|pages=1157–65; quiz 1166|pmid=18936903|doi=10.1007/s00106-008-1838-3|s2cid=30534218}}</ref> Some state that applying ice to the nose or forehead is not useful.<ref>{{Cite book |url=https://books.google.com/books?id=2LB0PC17uFsC&pg=PA711 |title=Oxford textbook of primary medical care. Buch, 1: Principles and concepts |date=2005 |publisher=Oxford Univ. Press |isbn=978-0-19-856782-0 |edition=1 |location=Oxford |pages=711}}</ref><ref>{{cite book|last=Bissonnette|first=Bruno|title=Pediatric Anesthesia|year=2010|publisher=McGraw-Hill Medical|location=New York|isbn=9781607950936|pages=1182|url=https://books.google.com/books?id=RYe4GBD6LrQC&pg=PA1182}}</ref> Others feel that it may promote vasoconstriction of the nasal blood vessels and thus be useful.<ref>{{cite book|last=al.]|first=A.Y. Elzouki ... [et|title=Textbook of clinical pediatrics|publisher=Springer|location=Berlin|isbn=9783642022012|pages=3968|url=https://books.google.com/books?id=FEf4EMjYSrgC&pg=PA3968|edition=2nd|date=2011-10-29}}</ref> In Indonesian traditional medicine, betel leaf is used to stop nosebleeds as it contains tannin which causes blood to coagulate, thus stopping active bleeding.<ref>{{Cite journal |last1=Tedjasulaksana |first1=Regina |last2=Nahak |first2=Maria Martina |last3=Larasati |first3=Ratih |date=2017-01-04 |title=Effectivity of Betel Leaf (Piper betle L.) Gel Extract in Shortening Bleeding Time After Deciduous Tooth Extraction |url=https://www.balimedicaljournal.org/index.php/bmj/article/view/374 |journal=Bali Medical Journal |language=en |volume=6 |issue=1 |pages=31–33 |doi=10.15562/bmj.v6i1.374 |issn=2302-2914|doi-access=free }}</ref>