Nosebleeds

I realized that nosebleeds are a relatively unusual thing for most people, and so they basically don’t have any idea how to deal with them or how concerned to be about them. I’ve had somewhere between 3,000 and 5,000 of them in my life, and so have some degree of practical wisdom/familiarity about them.

The most important observation is that nosebleeds are basically just wounds in your nose.

It follows that most of the advice about wound treatment and prevention applies to those (modulo the ways in which the inside of a nose is slightly but not entirely different from other skin).

For example, the most generally strong method of stopping nosebleeds is to apply pressure– pinch the soft or cartilaginous part of your nose about as high as possible and lean forward, and then wait for a clot to form over it (this usually takes 5-15 minutes). Later, it’s advisable to keep the wound moist, which you can do by literally putting something like Neosporin on the wound, straight up your nose, the same as you would with any other wound. (Vaseline is another common household trick, but I think it’s noticeably worse.) (It also follows that excessively dry air can trigger nosebleeds, and this can be counteracted by using a humidifier.) Also as with wounds, higher BP makes the wound likelier to rupture (and it’s likelier to rupture when you’re upside down), and having the wound farther above your heart helps you to have less effective BP.

Common advice

• There’s some common advice about tilting your head back. This is bad advice in that it doesn’t help the wound to close. If the wound is small enough, it closes in a short amount of time anyway, and in the meantime, at least the blood doesn’t come down out of your nose and make a mess, so in this case, it seems to work, and is actually a decent strategy. But if the wound is open enough that it will not spontaneously clot, this will not work for potentially a long time. Another downside of this is that the blood drains down the back of your throat, and into your stomach, and if enough blood gets into your stomach you will most likely throw up.

• Sometimes people suggest balling up a bit of tissue and then shoving it up your nose. This has similar effects; it mostly doesn’t help to stop the wound but does at least absorb the blood with a neutral head position so you can get on with your life.

• Sometimes people suggest applying ice or a wet towel to either your neck, your lip, or your forehead in the hope that this will cool down some relevant blood vessel. As far as I can tell, this isn’t very useful, in short, because most of these things don’t plausibly get the cold close enough to the blood vessels on the inside of your nose.

Minutiae

When you get nosebleeds really often, it’s good to have a detailed protocol for dealing with them with minimal interruption to your life. This is partly an art and partly a science.

• If you can sense that the bleed is very small, you can do the tilt-back trick, or even barely tilt your head backwards and then just breathe very carefully.
  • In some cases motion will trigger the bleed to accelerate by a lot. I’m not sure how to express this, but you can tell when there’s excess pressure in the affected blood vessel, and if you hold still for long enough, it will abate.
• If it’s slightly larger than that, the tissue trick is needed.
  • On the high end of the tissue trick range, you’ll want to shape the tissue in such a way that when you push it into your nose, it directly applies pressure on the wound. For this reason, and of course to avoid excess irritation, it’s better to use a softer material. You’d also like the material to be not too sticky or the shape too wide, for lack of a better word, so that it does not stick to the clot when you pull it out.
    • Assuming that the flow is fast enough that you need to do this, you can expect a sizeable clot to form. Pulling the tissue out early will reset your progress towards forming one, and also, you will need to drain the clot later (see below).
• Past a certain rate of flow, you should cut your losses and go straight to doing the most effective thing, which is to pinch your nose and lean forward. At this point, being in denial about getting interrupted and trying a worse variation will actively allow the bleed to get worse, and ultimately also get a lot more blood everywhere when you inevitably have to transition to doing the most effective thing (in a bad case, blood will just completely saturate the tissue that you’re using and then bleed through it). Doing the most effective thing actually allows you to not get much blood anywhere even in extremely high-flow cases, counterintuitively, as long as you just have discipline and patience about holding it until a sizeable clot forms, since basically no blood can make it out at all even if you’re not pinching that hard.
  • After a clot forms, there is a phase where it should stay over the wound as it closes. In this phase, you are “not actually actively bleeding”, but the clot is made of blood but not actually solid, and/or there’s a large reservoir of blood higher in your nasal cavity that’s able to diffuse through the clot, so blood will continue to come out of your nose. But in this phase you only need to manage not spilling blood, so you can actually pull the tissue trick (or just rinse out the lower part of your nose, if the amount of excess blood is quite small).
  • After some amount of time, the longer the safer, you can remove the clot just so that you can stop the flowing of the leftover blood and also so that you feel more comfortable. You can do this by inhaling it and coughing it up, blowing your nose, or effectively picking your nose (or have it stick to some tissue that’s in there). (These are listed in order of how disruptive they are, and hence likely they are to re-wound you.)
    • After a substantial bleed, the size of the clot would probably surprise most people, or at least most men. In the most severe cases the clot was probably equal in volume to my entire actual nose.
  • If you did not wait long enough and the clot is not large enough (or it gets dislodged by your motion, which also happens more often when it’s not large enough), the bleed will continue, even with a clot up your nose. In this case I’ve found it’s pretty hard to get another clot to fully cover the wound, and it’s usually better to try and clear the clot and start again, though in doing this sometimes you risk widening the wound and this sucks.
  • In really high flow situations you will start to bleed out the other nostril just from overflow of your nasal cavity. This isn’t a wound on that side so you don’t really need to do anything except for manage the blood flow, as above.
  • If you actually have bleeds in both nostrils, well, you’ll need to form a clot in both of them, and you will feel palpably higher pressure in your nose and have to breathe through your mouth. Trying to breathe through your nose in this case of course just risks dislodging them and resetting the process.

Note: I’ve heard it said that if you ever have a nosebleed lasting for longer than 20 minutes, you should go to the hospital. I am not a doctor, but I’ve probably had nosebleed lasting at least that long several hundred times, and never had to go to the hospital for it. (I think it’s a lot more alarming if you don’t already have nosebleeds often; in that case, it’s likelier to be indicative of something, but in my case, the bleeds were already explained away, so to speak.) Basically, I think if you don’t follow the correct protocol and have a reasonably large wound (large enough for the tissue trick to not automatically work), there basically isn’t any reason to expect the bleeding to stop within any short amount of time. However, as I got older and wiser and realized that I should cut my losses sometimes and/or deliberately not be a lazy bastard, I would more often jump straight to just doing the effective thing, and I’m not sure I’ve ever bled for more than 20 minutes if I did the most effective thing from the start.

Some other practical wisdom

• Changes in bleed rate are not necessarily very smooth/continuous. If you rupture a vessel which has recently been bleeding, a stream blood can basically start falling out of your face at the speed of gravity.

• If you are in public or just trying to get back to sleep or something, there is a temptation to always try and keep things clean. With a bleed of substantial speed this is self-defeating much of the time, and you would probably be better served cutting your losses, focusing on holding still and just doing the most effective thing to stop the bleed, and cleaning up after it’s very solidly under control. This is several times as true if you’re doing the tissue thing.

Miscellany

• I’ve heard that it’s comparatively common for children to have too many nosebleeds, and then they grow out of this when they’re 5-10. For some reason this didn’t happen to me, but it did seem to slow down when I was about 19.
• I’m pretty sure having a generally unhealthy diet or poor sleep predicts having more nosebleeds in a way that isn’t literally about blood pressure, but which is pretty highly correlated with it. Situations where you’d get “meat sweats” induce nosebleeds. Traditional Chinese medicine has a metaphorical concept of “internal heat” which is pretty predictive of this– this is one of the observations that led me to actually have sort of respect for traditional sources of knowledge in general.
  • One unintuitive prediction of the TCM system is that some fruits, including lychees, cause you to have nosebleeds, and also there are things you can drink, like chrysanthemum tea and grass jelly, which prevent nosebleeds.
• There are other major upstream causes of common nosebleeds, like inflammation or irritation from other stuff, like allergic reactions. I know a lot less about this.
• Some time at around the 30 or 40 minute mark you start to feel lightheaded and sort of sore in the face from loss of blood. This isn’t by itself an emergency, but obviously there’s some point after that where it becomes one.
• Sometimes, one gets pretty persistent nosebleeds because they have a particular blood vessel which is really fragile for some reason (maybe the cumulative damage of previous nosebleeds means it’s walled over with some shitty scar tissue or something); in this case you can cauterize the wound, usually chemically with something like silver nitrate. You’d achieve this by putting the cauterizing agent at the end of a narrow stick and then sticking it up your nose and applying pressure. This can hurt anywhere from “quite a bit for a little while” to “god awfully horrible”. The sort of tissue that grows over that reminds me of a tree trunk and sloughs off in about 7 days. I had this done 3 or 4 times growing up.
• For anyone who’s concerned about me, I did get tested for hemophilia and various other concerning reasons I would otherwise get a bunch of nosebleeds, and I don’t seem to have any of them.