What are the causes of spontaneous severe epistaxis (nose bleeds)?

From the Guidelines

Spontaneous severe nosebleeds (epistaxis) can be caused by several factors, with the most common being trauma, dry nasal passages, and hypertension, as stated in the 2024 American Heart Association and American Red Cross guidelines for first aid 1.

Causes of Epistaxis

The causes of spontaneous severe epistaxis can be categorized into several factors, including:

• Trauma: nose picking, facial injuries, or foreign objects in the nose
• Dry nasal passages: low humidity, heated indoor air, and allergies can dry out and irritate nasal membranes
• Hypertension: high blood pressure can increase the risk of bleeding
• Medical conditions: blood clotting disorders, liver disease, kidney disease, and certain medications like aspirin, NSAIDs, blood thinners (warfarin, apixaban), and some supplements (fish oil, vitamin E)
• Structural abnormalities: deviated septum or nasal polyps can also contribute to the development of epistaxis

Management and Prevention

For immediate management, sit upright, lean slightly forward, pinch the soft part of your nose for 10-15 minutes, breathe through your mouth, and apply ice to the bridge of your nose, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. If bleeding persists beyond 20 minutes, is extremely heavy, or recurs frequently, seek immediate medical attention. Prevention includes using saline nasal sprays, petroleum jelly inside nostrils, humidifiers in dry environments, and avoiding nose picking or forceful nose blowing. These measures help maintain the integrity of nasal blood vessels, which are numerous and close to the surface in the nasal cavity, making them vulnerable to rupture.

Key Recommendations

• Seek medical attention if bleeding does not stop after 15 minutes of continuous manual pressure or if you become lightheaded from epistaxis, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1
• It is reasonable for a person experiencing epistaxis who is taking anticoagulant or antiplatelet medication, or who has a blood-clotting disorder, to seek care from a health care professional, unless bleeding has stopped, as stated in the 2024 American Heart Association and American Red Cross guidelines for first aid 1

From the FDA Drug Label

WARNINGS The most serious risks associated with anticoagulant therapy with warfarin sodium are hemorrhage in any tissue or organ12 Signs and symptoms of bleeding include: ... nosebleeds

The causes of spontaneous severe epistaxis (nose bleeds) are not directly addressed in the provided drug labels, but hemorrhage is mentioned as a risk associated with anticoagulant therapy with warfarin sodium, and nosebleeds are listed as a sign or symptom of bleeding. However, the labels do not provide information on the causes of spontaneous severe epistaxis. 2 2

From the Research

Causes of Spontaneous Severe Epistaxis

• The exact causes of spontaneous severe epistaxis are not explicitly stated in the provided studies, but several factors can contribute to the condition, including:
  • Age: Epistaxis most commonly affects children and the elderly 3
  • Medications: Certain medications, such as clopidogrel, can increase the risk of bleeding 4
  • Trauma: Nasal fractures or breaks can cause epistaxis 5
  • Other medical conditions: Certain medical conditions, such as transitory ischemic attack, may require medications that increase the risk of bleeding 4

Treatment Options for Epistaxis

• Various treatment options are available for epistaxis, including:
  • First aid measures: External pressure and ice packing can stop 65-75% of nosebleeds 6
  • Topical agents: Oxymetazoline can stop bleeding in 65-75% of cases 6
  • Electrocautery: More effective and has fewer recurrences than chemical cauterization 6
  • Tranexamic acid: Promotes hemostasis in 78% of patients 6, 7
  • Nasal packing: Can be applied with non-absorbable or absorbable materials 6
  • Endoscopic ligation of arteries: More effective than conventional nasal packing 6
  • Embolization: Can be applied using gelatin sponge, foam, PVA, and coils with an 80% success rate 6

Effectiveness of Tranexamic Acid

• Tranexamic acid has been shown to be effective in reducing the risk of re-bleeding in patients with epistaxis 3, 7
• The use of tranexamic acid in addition to usual care has been found to reduce the risk of re-bleeding from 67% to 47% 3
• Topical tranexamic acid has been found to be probably better than other topical agents in stopping bleeding in the first 10 minutes 3