Editing Nosebleed

{{short description|Bleeding from the nose}}
{{Other uses}}
{{Infobox medical condition (new)
| name            =
| image           = Young_child_with_nosebleed,_smiling_cropped.jpg
| synonyms        = Epistaxis, bloody nose, nasal hemorrhage<ref name=Fer2013/>
| caption         = A three-year-old child with a minor nosebleed from falling and hitting his face on the floor
| pronounce       = Epistaxis {{IPAc-en|ˌ|ɛ|p|ᵻ|ˈ|s|t|æ|k|s|ᵻ|s}} {{respell|EP|ih|STAK|sis}}
| field           = [[Otorhinolaryngology]]
| symptoms        = Bleeding from the nose<ref name=Fer2013/>
| complications   =
| onset           = Less than 10 and over 50 years old<ref name=AFP2005/>
| duration        =
| types           =
| causes          =
| risks           = Trauma, excessive [[nose picking]], certain [[infection]]s, [[anticoagulants|blood thinners]], [[high blood pressure]], [[alcoholism]], [[seasonal allergies]], dry weather<ref name=Stat2019/>
| diagnosis       = Direct observation<ref name=Fer2013/>
| differential    = [[Hemoptysis|Bleeding from the lungs]], [[esophageal varices]],<ref name=Fer2013/> [[vomiting blood]]
| prevention      = [[Petroleum jelly]] in the nose<ref name=Kell2014/>
| treatment       = Pressure over the lower half of the nose, [[nasal packing]], [[endoscopy]]<ref name=Tun2020/>
| medication      = [[Tranexamic acid]]<ref name=Jos2018/>
| prognosis       =
| frequency       = 60% at some point in time<ref name=Wac2009/>
| deaths          = Rare<ref name=Stat2019/>
}}
<!-- Definition and symptoms -->
A '''nosebleed''', also known as '''epistaxis''', is an instance of [[bleeding]] from the [[nose]].<ref name=Fer2013>{{cite book |last1=Ferri |first1=Fred F. |title=Ferri's Clinical Advisor 2014 E-Book: 5 Books in 1 |date=2013 |publisher=Elsevier Health Sciences |isbn=978-0-323-08431-4 |page=399 |url=https://books.google.com/books?id=H63KViNwsdcC&pg=PA399 |language=en}}</ref> [[Blood]] can flow down into the stomach, and cause [[nausea]] and [[vomiting]].<ref>{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK411/|title=Clinical Methods: The History, Physical, and Laboratory Examinations|last=Wilson|first=I. Dodd|date=1990|publisher=Butterworths|isbn=978-0409900774|editor-last=Walker|editor-first=H. Kenneth|edition=3rd|location=Boston|pmid=21250251|editor-last2=Hall|editor-first2=W. Dallas|editor-last3=Hurst|editor-first3=J. Willis}}</ref> In more severe cases, blood may come out of both [[nostrils]].<ref>{{cite journal |last1=Krulewitz |first1=NA |last2=Fix |first2=ML |title=Epistaxis. |journal=Emergency Medicine Clinics of North America |date=February 2019 |volume=37 |issue=1 |pages=29–39 |doi=10.1016/j.emc.2018.09.005 |pmid=30454778|s2cid=242676103 }}</ref> Rarely, bleeding may be so significant that [[low blood pressure]] occurs.<ref name=Fer2013/> Blood may also be forced to flow up and through the [[nasolacrimal duct]] and out of the eye, producing [[haemolacria|bloody tears]].<ref>{{cite book |last1=Riordan-Eva |first1=Paul |title=Vaughan and Asbury's General Ophthalmology |date=2000 |publisher=McGraw Hill Professional |isbn=978-0-07-137831-4 |page=92 |language=en}}</ref>

<!-- Cause and diagnosis -->
Risk factors include trauma, including putting the finger in the nose, [[anticoagulants|blood thinners]], [[high blood pressure]], [[alcoholism]], [[seasonal allergies]], dry weather, and [[inhaled corticosteroid]]s.<ref name=Stat2019/> There are two types: anterior, which is more common; and posterior, which is less common but more serious.<ref name=Stat2019>{{cite journal |last1=Tabassom |first1=A |last2=Cho |first2=JJ |title=Epistaxis (Nose Bleed) |journal=StatPearls |date=January 2020 |pmid=28613768}}</ref> Anterior nosebleeds generally occur from [[Kiesselbach's plexus]] while posterior bleeds generally occur from the [[sphenopalatine artery]] or [[Woodruff's plexus]].<ref name=Stat2019/> The diagnosis is by direct observation.<ref name=Fer2013/>

<!-- Prevention and treatment -->
Prevention may include the use of [[petroleum jelly]] in the nose.<ref name=Kell2014>{{Cite journal|last1=Morgan|first1=Daniel J.|last2=Kellerman|first2=Rick|date=March 2014|title=Epistaxis|journal=Primary Care: Clinics in Office Practice|volume=41|issue=1|pages=63–73|doi=10.1016/j.pop.2013.10.007|pmid=24439881|issn=0095-4543|doi-access=free}}</ref> Initially, treatment is generally the application of pressure for at least five minutes over the lower half of the nose.<ref name=Tun2020>{{cite journal |last1=Tunkel |first1=David E. |last2=Anne |first2=Samantha |last3=Payne |first3=Spencer C. |last4=Ishman |first4=Stacey L. |last5=Rosenfeld |first5=Richard M. |last6=Abramson |first6=Peter J. |last7=Alikhaani |first7=Jacqueline D. |last8=Benoit |first8=Margo McKenna |last9=Bercovitz |first9=Rachel S. |last10=Brown |first10=Michael D. |last11=Chernobilsky |first11=Boris |last12=Feldstein |first12=David A. |last13=Hackell |first13=Jesse M. |last14=Holbrook |first14=Eric H. |last15=Holdsworth |first15=Sarah M. |last16=Lin |first16=Kenneth W. |last17=Lind |first17=Meredith Merz |last18=Poetker |first18=David M. |last19=Riley |first19=Charles A. |last20=Schneider |first20=John S. |last21=Seidman |first21=Michael D. |last22=Vadlamudi |first22=Venu |last23=Valdez |first23=Tulio A. |last24=Nnacheta |first24=Lorraine C. |last25=Monjur |first25=Taskin M. |title=Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary |journal=Otolaryngology–Head and Neck Surgery |date=7 January 2020 |volume=162 |issue=1 |pages=8–25 |doi=10.1177/0194599819889955|pmid=31910122 |s2cid=210072386 |doi-access= }}</ref> If this is not sufficient, [[nasal packing]] may be used.<ref name=Tun2020/> [[Tranexamic acid]] may also be helpful.<ref name=Jos2018>{{Cite journal|last1=Joseph|first1=Jonathan|last2=Martinez-Devesa|first2=Pablo|last3=Bellorini|first3=Jenny|last4=Burton|first4=Martin J|date=2018-12-31|editor-last=Cochrane ENT Group|title=Tranexamic acid for patients with nasal haemorrhage (epistaxis)|journal=Cochrane Database of Systematic Reviews|volume=2018|issue=12|pages=CD004328|language=en|doi=10.1002/14651858.CD004328.pub3|pmc=6517002|pmid=30596479}}</ref> If bleeding episodes continue, [[endoscopy]] is recommended.<ref name=Tun2020/>

<!-- Epidemiology -->
About 60% of people have a nosebleed at some point in their life.<ref name=Wac2009>{{cite book|url=https://books.google.com/books?id=sGhzMnst1j8C&pg=PA551|title=Ballenger's otorhinolaryngology : head and neck surgery.|last1=Wackym|first1=James B. Snow,... P. Ashley|date=2009|publisher=People's Medical Pub. House/B C Decker|isbn=9781550093377|edition=17th|location=Shelton, Conn.|page=551}}</ref> About 10% of nosebleeds are serious.<ref name=Wac2009/> Nosebleeds are rarely fatal, accounting for only 4 of the 2.4 million deaths in the U.S. in 1999.<ref>{{cite web |title=Work Table I. Deaths from each cause by 5-year age groups, race and sex: US, 1999 |url=https://www.cdc.gov/nchs/data/statab/vs00199wktbli.pdf |website=CDC |access-date=13 April 2020 |page=1922 |date=2011}}</ref> Nosebleeds most commonly affect those younger than 10 and older than 50.<ref name=AFP2005>{{Cite journal|last1=Kucik|first1=Corry J.|last2=Clenney|first2=Timothy|date=2005-01-15|title=Management of epistaxis|journal=American Family Physician|volume=71|issue=2|pages=305–311|issn=0002-838X|pmid=15686301}}</ref>
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== Cause ==
[[File:Boxing children - bloody nose.jpg|thumb|right|350px|Two children [[boxing]], the one on the right having a nosebleed due to a punch to the face, in [[Vecsés]], [[Hungary]] in November 2006]]
Nosebleeds can occur due to a variety of reasons. Some of the most common causes include trauma from [[nose picking]], blunt trauma (such as a motor vehicle accident), or insertion of a foreign object (more likely in children).<ref name=Kell2014 /> Low [[relative humidity]] (such as in centrally heated buildings), [[respiratory tract infection]]s, [[chronic sinusitis]], [[rhinitis]] or environmental [[Irritant (biology)|irritant]]s can cause inflammation and thinning of the tissue in the nose, leading to a greater likelihood of bleeding from the nose.<ref name=Kell2014/>

Most causes of nose bleeding are self-limiting and do not require medical attention. However, if nosebleeds are recurrent or do not respond to home therapies, an underlying cause may need to be investigated. Some rarer causes are listed below:<ref name=AFP2005/><ref name=Kell2014 /><ref name=":1">{{Cite journal|last1=Svider|first1=Peter|last2=Arianpour|first2=Khashayar|last3=Mutchnick|first3=Sean|date=June 2018|title=Management of Epistaxis in Children and Adolescents|journal=Pediatric Clinics of North America|volume=65|issue=3|pages=607–621|doi=10.1016/j.pcl.2018.02.007|pmid=29803286|s2cid=44125103|issn=0031-3955}}</ref>

'''Coagulopathy'''
* [[Thrombocytopenia]] ([[thrombotic thrombocytopenic purpura]], [[idiopathic thrombocytopenic purpura]])
* [[Von Willebrand's disease]]
* [[Hemophilia]]
* [[Leukemia]]
* [[HIV]]
* [[Chronic liver disease]]—cirrhosis causes deficiency of factor II, VII, IX,& X

'''Dietary'''
* [[Sulfur dioxide]] (sulphur dioxide) E220 (as a [[food preservative]] used particularly in wines and dried fruits)
* [[Sulphites]] as [[food preservatives]]
* [[Salicylates]] naturally occurring in some fruits and vegetables

'''Inflammatory'''
* [[Granulomatosis with polyangiitis]]
* [[Systemic lupus erythematosus]]

'''Medications/Drugs'''
* [[Anticoagulation]] ([[warfarin]], [[heparin]], [[aspirin]], etc.)
* [[Insufflation (medicine)|Insufflated]] drugs (particularly [[cocaine]])
* [[Nasal spray]]s (particularly prolonged or improper use of nasal steroids)

'''Neoplastic'''
* [[Squamous cell carcinoma]]
* [[Adenoid cystic carcinoma]]
* [[Melanoma]]
* [[Nasopharyngeal carcinoma]]
* [[Nasopharyngeal angiofibroma]]
* Nosebleeds can be a sign of cancer in the sinus area, which is rare, or tumors starting at the base of the brain, such as [[meningioma]]. Due to the sensitive location, nosebleeds caused by tumors are typically associated with other symptoms, such as hearing or vision problems.<ref>{{Cite web|date=2020-11-19|title=Nosebleeds & Headaches: Do You Have Brain Cancer?|url=https://ana-neurosurgery.com/symptoms-brain-tumor/|access-date=2020-12-14|website=Advanced Neurosurgery Associates|language=en-US}}</ref>

'''Traumatic'''
* [[Deformity|Anatomical deformities]] (''e.g.'' septal spurs)
* [[Blunt trauma]] (usually a sharp blow to the face such as a punch, sometimes accompanying a [[nasal fracture]])
* [[Foreign body|Foreign bodies]] (such as fingers during [[nose-picking]])
* Digital trauma ([[nose picking]])
* [[Middle ear]] [[barotrauma]] (such as from descent in aircraft or ascent in scuba diving)
* [[Nasal bone]] fracture
* Septal fracture/perforation
* Intranasal [[tumor]]s (''e.g.'' [[Nasopharyngeal carcinoma]] or [[nasopharyngeal angiofibroma]])
* [[Nasal cannula]] O<sub>2</sub> (tending to dry the [[olfactory mucosa]])
* [[Nasal spray]]s (particularly prolonged or improper use of nasal steroids)
* [[Surgery]] (''e.g.'' [[septoplasty]] and [[functional endoscopic sinus surgery]])
* [[Leech]] infestation<ref>{{cite journal |author=Yueng-Hsiang Chu & Jih-Chin Lee |url=http://content.nejm.org/cgi/content/full/361/9/e14 |title=Unilateral Epistaxis |journal=[[New England Journal of Medicine]] |year=2009 |volume=361 |pages=e14 |pmid=19710479 |doi=10.1056/NEJMicm0807268 |issue=9|url-access=subscription }}</ref>
* Nasal bleeds may be due to fracture of facial bones namely maxilla and zygoma.

'''Vascular'''
* [[Hereditary hemorrhagic telangiectasia]] (Osler–Weber–Rendu disease)
* [[Angioma]]
* [[Aneurysm]] of the carotid artery

== Pathophysiology ==
[[File:Arteries of the Nose.jpg|alt=|thumb|upright=1.5|The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds)]]
The nasal [[Mucous membrane|mucosa]] contains a rich blood supply that can be easily ruptured and cause bleeding. Rupture may be spontaneous or initiated by trauma. Nosebleeds are reported in up to 60% of the population with peak incidences in those under the age of ten and over the age of 50 and appear to occur in males more than females.<ref name="AAFP">{{cite journal |url=http://www.aafp.org/afp/20050115/305.html |title=Management of Epistaxis |journal=American Family Physician |volume=71 |issue=2 |pages=305–311 |author1=Corry J. Kucik |author2=Timothy Clenney |date=January 15, 2005 |access-date=January 31, 2010 |publisher=[[American Academy of Family Physicians]] |pmid=15686301 |archive-date=August 29, 2008 |archive-url=https://web.archive.org/web/20080829203041/http://www.aafp.org/afp/20050115/305.html |url-status=dead }}</ref> An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaneous epistaxis.<ref>{{cite journal |doi=10.1097/00005537-199907000-00019 |author1=J. F. Lubianca Neto |author2=F. D. Fuchs |author3=S. R. Facco |author4=M. Gus |author5=L. Fasolo |author6=R. Mafessoni |author7=A. L. Gleissner |title=Is epistaxis evidence of end-organ damage in patients with hypertension? |journal=Laryngoscope |year=1999 |volume=109 |issue=7 |pages=1111–1115 |pmid=10401851|s2cid=22724992 }}</ref> [[Anticoagulant]] medication and disorders of blood clotting can promote and prolong bleeding. Spontaneous epistaxis is more common in the elderly as the nasal mucosa (lining) becomes dry and thin and blood pressure tends to be higher. The elderly are also more prone to prolonged nosebleeds as their blood vessels are less able to constrict and control the bleeding.

The vast majority of nosebleeds occur in the front [[anterior]] (front) part of the nose from the [[nasal septum]]. This area is richly endowed with blood vessels ([[Kiesselbach's plexus]]). This region is also known as [[Little's area]]. Bleeding farther back in the nose is known as a posterior bleed and is usually due to bleeding from [[Woodruff's plexus]], a venous plexus situated in the posterior part of inferior meatus.<ref>
The Journal of Laryngology & Otology (2008), 122: 1074–1077</ref> Posterior bleeds are often prolonged and difficult to control. They can be associated with bleeding from both nostrils and with a greater flow of blood into the mouth.<ref name="AAFP" />

{{Anchor|Pseudoepistaxis}} Sometimes blood flowing from other sources of bleeding passes through the nasal cavity and exits the nostrils. It is thus blood coming from the nose but is not a true nosebleed, that is, not truly originating from the nasal cavity. Such bleeding is called "pseudoepistaxis" (''[[wikt:pseudo-#Prefix|pseudo]]'' + ''epistaxis''). Examples include [[hemoptysis|blood coughed up]] through the [[airway]] and ending up in the nasal cavity, then dripping out.

==Prevention==
{{Expand section|date=February 2023}}
People with uncomplicated nosebleeds can use conservative methods to prevent future nosebleeds such as sleeping in a humidified environment or applying [[petroleum jelly]] to the nasal [[Nostril|nares]].<ref name="Kell2014" />

Individuals who suffer from nosebleeds regularly, especially children, are encouraged to use over-the-counter nasal saline sprays and avoid vigorous nose-blowing as preventative measures.<ref>{{Cite web |date=25 July 2023 |title=Taking control of nosebleeds - Mayo Clinic Health System |url=https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/taking-control-of-nosebleeds |access-date=29 April 2024}}</ref>

== 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>

==Society and culture==
In the visual language of Japanese [[manga]] and [[anime]], nosebleeding often indicates that the bleeding person is sexually aroused.<ref name=Metroactive>{{cite news|title=Manga: The Complete Guide, reviewed by Richard von Busack|url=http://www.metroactive.com/metro/01.16.08/books-manga-0803.html|access-date=5 August 2011|newspaper=[[Metro Silicon Valley|Metroactive]]}}</ref><ref name="Sydney Morning Herald">{{cite news|last=Morgan|first=Joyce|title=Superheroes for a complex world|url=http://www.smh.com.au/news/books/superheroes-for-a-complex-world/2007/02/08/1170524225116.html|access-date=5 August 2011|newspaper=[[The Sydney Morning Herald]]|date=February 10, 2007}}</ref><ref name=ANN>{{cite news|title=Anime Physics: Nosebleeds|url=http://www.animenewsnetwork.com/interest/2010-07-17/anime-physics/nosebleeds|accessdate=5 August 2011|newspaper=[[Anime News Network]]|date=17 July 2010}}</ref> In [[Western media|Western fiction]], nosebleeds often signify intense mental focus or effort, particularly during the use of psychic powers.<ref name="st-psychic-nosebleeds">{{cite web | url=http://daily.jstor.org/stranger-things-and-psychic-nosebleeds/ | title="Stranger Things" and the Psychic Nosebleed | publisher=JSTOR Daily | date=30 August 2016 | access-date=6 November 2016 | author=Tracey, Liz}}</ref><ref name="nosebleed-cinema">{{cite book | url=https://books.google.com/books?id=sPAqEWLVa5QC&q=epistaxis+telepathica&pg=PA187 | title=Cinema of the Psychic Realm: A Critical Survey | publisher=McFarland | author=Meehan, Paul | pages=193| isbn=9780786454747 | date=2009-10-21 }}</ref>

In American and Canadian usage, "[[nosebleed section]]" and "nosebleed seats" are common slang for seating at sporting or other spectator events that are the highest up and farthest away from the event. The reference alludes to the propensity for nasal hemorrhage at high altitudes, usually owing to lower barometric pressure.

The oral history of the Native American [[Sioux]] tribe includes reference to women who experience nosebleeds as a result of a lover's playing of music, implying sexual arousal.<ref>{{cite book |last=Various |title=American Indian Myths and Legends |edition=2 |editor-last=Erdoes |editor-first=Richard |editor2-last=Ortiz |editor2-first=Alfonso |location=Toronto, Ontario |publisher=Random House of Canada Limited |year=1984 |page=274 }}</ref>

In the [[Finnish language]], "picking blood from one's nose" and "begging for a nosebleed" are commonly used in abstract meaning to describe self-destructive behaviour, for example ignoring safety procedures or deliberately aggravating stronger parties.<ref>{{Cite web|url=http://saaressa.blogspot.fr/2011/01/finnsh-idioms.html|title=Finnish idioms and proverbs|website=saaressa.blogspot.fr|access-date=2017-12-19}}</ref>

In [[Filipino people|Filipino]] slang, to "have a nosebleed" is to have serious difficulty conversing in English with a fluent or native English speaker. It can also refer to anxiety brought on by a stressful event such as an [[Test (assessment)|examination]] or a [[job interview]].<ref>[http://liveinthephilippines.com/content/omg-nosebleed-say-what/ OMG! Nosebleed! Say what?!] {{Webarchive|url=https://web.archive.org/web/20131020150535/http://liveinthephilippines.com/content/omg-nosebleed-say-what/ |date=2013-10-20 }} Retrieved 28 August 2013</ref>

In the [[Dutch language]], "pretending to have a nosebleed" is a saying that means pretending not to know anything about something.<ref>{{cite web |title=Doen alsof je neus bloedt |url=https://onzetaal.nl/taaladvies/doen-alsof-je-neus-bloedt |website=OnzeTaal |access-date=8 June 2020 |archive-date=8 June 2020 |archive-url=https://web.archive.org/web/20200608092828/https://onzetaal.nl/taaladvies/doen-alsof-je-neus-bloedt |url-status=dead }}</ref>

===Etymology===
The word ''epistaxis'' is from {{langx|grc|ἐπιστάζω}} ''epistazo'', "to bleed from the nose" from {{lang|grc|ἐπί}} ''epi'', "above, over" and {{lang|grc|στάζω}} ''stazo'', "to drip [from the nostrils]".{{citation needed|date=May 2021}}

==References==
{{Reflist}}

== External links ==
*{{commons-inline}}

{{Medical resources
|  DiseasesDB = 18327
|  ICD11 = {{ICD11|MD20}}, {{ICD11|KA83.A}}
|  ICD10 = {{ICD10|R04.0}}
|  ICD9 = {{ICD9|784.7}}
|  ICDO =
|  OMIM =
|  MedlinePlus = 003106
|  eMedicineSubj = emerg
|  eMedicineTopic = 806
|  eMedicine_mult = {{eMedicine2|ent|701}}
}}
{{Circulatory and respiratory system symptoms and signs}}
{{Bleeding and clotting disorders|us=y}}
{{Portal bar|Medicine}}
{{Authority control}}

[[Category:Bleeding]]
[[Category:First aid]]
[[Category:Nose disorders]]
[[Category:Wikipedia medicine articles ready to translate]]
[[Category:Symptoms and signs: Respiratory system]]
[[Category:Otorhinolaryngology]]