The Nose: Bleeds, Breaks, and Obstructions

Responding to a call for a female stablehand who had been kicked in the face by a horse, EMS providers found the patient awake, lying supine, in obvious pain and crying. Her nose had been crushed, and she had large bruises under her eyes, other facial deformity and blood oozing from her nose and around her eyes. In the next few minutes, both eyes swelled shut.

You may think it’s a waste of time to call EMS for a nosebleed; however, a nosebleed, break or obstruction can be or become a serious medical problem. Patients with nose problems may call EMS instead of self-transporting for a number of reasons: They have repeated nosebleeds; they are on blood-thinning medications or have an underlying disease process that affects blood clotting; friends and family notice the worrisome signs of hypovolemia; the patient begins to cough or vomit blood; or they are simply unable to drive to the hospital.

Anatomy of the Nose

The nose is a gateway to the airway and assists in critical functions related to breathing. It is a combination of tissue, bone and cartilage that is centered in the face superior to the mouth and between the eyes. The visible external structure of the nose consists of the nares or nostrils; the bridge, which is the bony upper third; and a cartilaginous structure that is covered by muscle and skin and makes up the bottom third. The strong outer structures of the nose protect the delicate internal structures of the nasal cavity.1

The underlying skeletal structure of the nose is a combination of bones and cartilage. The maxillary bone is the upper jaw and the lower border of the orbits, just above which are the nasal bones. Ethmoid and sphenoid bones are internal bones that help form the sinuses. It is the combination of maxillary, frontal, nasal, ethmoid and sphenoid bones that creates the lateral and superior walls of the nasal cavity. The mouth’s hard and soft palate is the base of the nasal cavity.2

Air enters the nose via the nostrils. The nasal septum divides the inner nose into two cavities. The septum, with the turbinates, regulates the flow of air and creates resistance.1 The septum is a combination of bone in the posterior portion and cartilage in the superior portion.

The lateral wall of the nasal cavity supports the inferior, middle and superior turbinates. The nasopharynx is the posterior portion of the nose where the right and left nasal cavities rejoin. The sinuses, eustachian tubes and nasolacrimal (tear) ducts connect with the nasal cavity. Connecting structures assist with nasal functions of filtration and air warming, elimination of irritant particles and pressure equalization.2

The nasal cavity is highly vascular. Small vessels bring blood to the external nose, nasal septum, nasal cavity and sinuses. One of these networks of vessels, called Kiesselbach’s plexus, perfuses the anterior nasal septum, which is where most nosebleeds occur.1 A thin nasal mucosa covers nasal septum vessels, making the nose susceptible to bleeding from trauma and medical causes. When the mucosa dries, scabs or falls off, the vessels are vulnerable to bleeding.

Nasal cavity tissues help protect the airway from microorganisms and allergens. Coarse hairs, sebaceous glands and sweat glands are in the anterior third of the nose.1 The nasal cavity is enclosed and protected by a membranous cellular tissue called epithelium, which produces the mucous covering for the nasal cavity. It also has a high concentration of ciliated cells, which have a short hair-like process that helps trap and move particulates out of the upper airway.1

Nose Function

The nose performs a complex set of ventilation and odor sensation functions. It filters, warms and humidifies air, and also helps protect the lower airway by triggering immunologic and inflammatory responses to allergens, pollutants and other particles.1

The aptly named turbinates make entering air turbulent by increasing air resistance and slowing its velocity. Arterial blood flow in the nose runs anteriorly, or toward the front, meaning blood flows in the opposite direction of inhaled air.1 This helps to progressively warm inhaled air as it moves toward the nasopharynx. In this short distance, the temperature of inhaled air nears body temperature, and humidity reaches above 80%.

As air is inhaled into the nose, it rushes into the nasal cavity, where coarse hair just at the nares’ opening helps remove large particulates.

Three turbinate bones funnel entering air toward the sinuses, where bacteria are removed and the air is moistened and warmed. Turbinates increase nasal cavity surface area and disrupt the flow of air. The turbulent flow of air helps deposit smaller particulates on the mucous membrane.2 Particulates that are trapped in the mucous cilia, including microorganisms, irritants and allergens, flow posteriorly, where they are either ejected with saliva or ingested and destroyed by gastric enzymes.1

The sense of smell plays a role in food intake, flavor perception, and detecting and warning about toxic or irritating substances.1 Odor particulates contact with the mucous lining of the nose and travel through the mucous lining to nerve receptor cells that communicate the odor to the brain. Do you remember certain calls by the way they smelled? Fortunately, the sense of smell easily fatigues to continuous odor exposure, allowing us to stay focused on the medical needs of our patient.1

Injuries

A nosebleed, or epistaxis, is acute bleeding from the nostril, nasal cavity or nasopharynx. Nosebleeds are common, affecting one in seven people. They are most common for children age 2–10 and adults age 50–80.

Nosebleeds are often seen during winter months; in dry, cold climates; and usually in the morning.3–5

Although nosebleeds are commonly associated with hypertension, they are not directly caused by it. Rather, the weakening of blood vessels that occurs with chronic hypertension increases the occurrence of epistaxis for hypertension patients.5

There are three reasons for nosebleed: External trauma to the nose can initiate a nosebleed, like being hit in the face by a basketball; internal trauma, such as nose-picking or irritation from cold, dry air can open a blood vessel on the septum, causing a nosebleed; and underlying disease processes can lead to nosebleeds.3

There are two types of epistaxis: anterior or posterior. Ninety percent of nosebleeds are from anterior sources. Bleeding is from the blood vessels of the nasal septum.6 Small capillaries or veins are close to the surface and can be exposed and broken open by damage to the mucous surface.

Posterior bleeding typically has an arterial source and is from vessels further back, or posterior, in the nasal cavity.6 Posterior bleeding is more likely to drain into the pharynx, which can lead to frequent spitting or swallowing blood.

The most frequent causes of epistaxis in pediatric patients are minor nasal trauma from nose-picking or irritation to mucous membranes after inserting a foreign body into the nose.

It is unlikely that EMS will be called for a toddler with a nosebleed after nose-picking or exploring with a crayon; however, if the child has an underlying medical problem that could lead to bleeding disorders, such as excessive coughing from pertussis, liver disease, leukemia or nasal tumors, EMS might be called to assist in transport of a sick child who now has a nosebleed.6

Traumatic collisions, slips and falls during play and organized sports also cause pediatric epistaxis. Bleeding from trauma is often from anterior sources on the nasal septum or along the nasal walls.4

Nasal fractures account for about 40% of facial fractures.7 The nose is most susceptible to fracture due to its prominent position, central location and low breaking threshold.

Any facial fracture is the result of trauma over a relatively small surface area. Imagine the horse hoof mentioned previously or a well-hit racquetball. Fortunately, most nasal fractures are minor injuries, but there is potential for serious and life-threatening injuries.

A fractured facial bone is often the result of a sports injury or motor vehicle accident. In sport-related fractures, the injury can come from contact with another player, contact with high-velocity moving objects, like a baseball or hockey puck, and contact with stationary objects within the field of play.8

Nasal fractures are most common in patients ages 15–30 and often occur from altercations and sporting injuries. Motor vehicle collisions are also a cause of nasal fractures. Not surprisingly, many nose breaks occur during or after alcohol and/or drug use.9 Nearly 80% of nasal fractures occur in the lower third to half of the nasal bones at the transition between thicker and thinner bones and cartilage structure.7

Epistaxis from trauma or medical reasons is the most common and most likely obstruction of the nasal cavity. Intentional and accidental insertion of foreign bodies, especially by infants and toddlers, is a potential reason for an EMS call or emergency department visit.

Children ages 1–8 are most likely to insert objects in their nose. There is no limit to the type of objects, including toy and game pieces and rocks. Direct visualization of the object may or may not be possible.10

Trauma can push objects completely out of view.10 For example, a blow to the face during an altercation could push a nose piercing out of position and into the nasal cavity.

There is a high risk, especially for children, that a foreign body could pass through the nasal cavity into the oropharynx and be aspirated, causing a full or partial airway obstruction.

Treatment

As with any incident, EMS providers need to first identify the mechanism of injury, which will help define the severity of the problem and the course of action.

The nose is one of two entrances to the upper airway. An open and intact nasal structure is critical to having an open airway and adequate ventilation. Whether from trauma or other causes, uncontrolled nasal bleeding can cause hypovolemia. Trauma to the nose may be the only outward indicator of trauma to underlying bones of the face, as well as to the brain and the cervical spine.

Regardless of the mechanism, your first concerns are airway, breathing and circulation. Check the patient’s airway and, if necessary, remove foreign bodies and debris. If there is nasal trauma, the greater threat to the patient is not from damaged or dislocated bones, but from swelling and blood obstructing the airway.2 If excessive bleeding or bone damage is present, a simple oral airway or intubation may be indicated. A sitting or lateral position is best because it prevents an airway obstruction.

Cervical spine injuries are present in 1%–4% of patients with facial fractures.8 Because of the force necessary to damage the strong bones of the face, cervical spine immobilization is indicated until a spine injury can be ruled out.

Nasal fractures can be minor or major. Indications of severe nasal fracture include persistent bleeding from one or both nostrils; CSF drainage from the nose; injury to surrounding bones and tissues, like the orbits, teeth or eyes; loss of consciousness; severe headache; persistent vomiting; and impaired vision. Additionally, neck pain and/or extremity numbness or weakness are indications that a nasal fracture is severe and needs emergency department evaluation.

During the detailed physical exam, inspect and palpate the nasal bone, frontal bone, maxillary bone, mandible and zygomatic bones for pain, tenderness and deformity.7 Deformity, tenderness, pain, epistaxis and/or bruising around the nose and below the eyes is evidence of a broken nose.7

Nasal deformity can include the nose being pushed laterally or posteriorly. Normal movement of the nose is limited to the anterior external tissue and cartilage surrounding the nares. Movement of the septum or underlying nasal bone is a sign of nasal fracture. Also check for any numbness or facial pain, visual acuity and pupil size and reaction. Note that post-trauma swelling can hide nasal crepitus, deformity and instability.7

You can also check for airflow by asking the patient to obstruct one side of the nose and gently blow out. Uneven air flow could be caused by obstruction, excess mucus or a deviated septum.2

Because the posterior wall of the facial bones is adjacent to the dura mater, facial trauma can result in central nervous system complications like cerebrospinal fluid leakage.7 If the cause of epistaxis or any other fluid draining from the nose is trauma, inspect the fluid for CSF.

A method to determine the presence of CSF is to place a drop of the fluid onto a piece of gauze or bed sheet. CSF will spread faster than blood. The resulting stain is a target-like shape with blood in the middle and blood-tinged CSF in the outer ring. The absence or presence of CSF does not alter the need to control anterior nose bleeding by pinching the nostrils.

After assuring ABCs and conducting a detailed physical exam, begin or continue bleeding control, firmly pinching the nostrils for 10 minutes or more to control anterior bleeding. Elevate the patient’s head, apply an ice pack to reduce swelling and administer pain medication following local protocols.

Nasal airways, nasogastric tubes and nasotracheal intubation are contraindicated for patients with nose trauma because of the possibility of a basal skull fracture. An opening in the posterior wall of the nasal cavity may allow any of these devices to enter the cerebral cavity and cause brain damage.2

If called to assist a patient with a nosebleed, your treatment priorities are to ensure an open airway, control bleeding, and gather current incident and medical history to attempt to identify the cause.

It may be possible to determine the source of the nosebleed by the flow of blood. I have seen blood gushing between fingers held over the patient’s face, two hands pressing blood-soaked towels against the chin, and one patient who walked into the emergency department holding an overflowing 12-ounce glass of blood under her nose. Anterior nosebleeds produce a steady ooze. If the patient has a posterior bleed, you may observe profuse spurting of arterial blood.6 Bleeding usually occurs from just one nostril.3 Bleeding from both nares and seeing blood draining into the oropharynx are also indications of a posterior bleed.5

Nasal bleeding can be the source of blood that triggers hemoptysis or hematemesis. Since 90% of nosebleeds are from anterior sources, most of the blood comes out of the nares. Posterior bleeding can drain into the mouth and cause a gagging cough. Alternatively, if the patient swallows the blood, just a small amount can irritate the stomach lining and the patient may have bloody vomit or hematemesis.

During the focused history, ask the patient how it has been bleeding; which nostril bled first; previous nosebleed episodes; existence of hypertension, liver disease or other medical problems; and medication use. Some medications may not only predispose a patient to epistaxis, but also make controlling bleeding more difficult. Those medications include aspirin, nonsteroidal anti-inflammatory drugs, warfarin (Coumadin) and heparin.5

Because an active nosebleed, especially posterior bleeding, can produce a significant amount of blood, use personal protective equipment—gloves, mask, goggles and gown. Immediately assess airway adequacy to determine whether suction is needed. Severe posterior bleeds can obstruct the pharynx and require a Combitube or ET tube. Assisted oxygen may be helpful to the patient, but a nasal cannula might quickly clog with blood, and a non-rebreather will make it difficult to apply direct pressure to control the bleeding. In addition, the patient is likely going to need to spit, gag or vomit.

Bleeding Control

A lot of nosebleeds, especially in healthy patients, will stop spontaneously. Since 90% or more of nosebleeds are anterior, they are easy to treat with simple, well-aimed direct pressure. Depending on the length of time the nose has been bleeding and treatment prior to EMS’s arrival, start by removing any packing the patient has inserted into the nares. Anterior packing will not control a severe anterior or posterior bleed.

Have the patient blow out any poorly formed clots into a handful of tissues. Be prepared with an emesis basin, as this can be messy.

Next, have the patient sit upright and lean the head slightly forward to prevent aspirating or swallowing blood. Have the patient apply well-aimed direct pressure to both nostrils. This is best done by firmly pinching the nostrils together and holding pressure for at least 10 minutes. Do not recheck for bleeding until after 10 minutes. Any release of pressure minimizes clotting effectiveness. If the patient is unable, apply direct pressure in the same fashion with your gloved hand.

Well-aimed direct pressure will stop most bleeding. If bleeding persists, continue well-aimed direct pressure, suction as necessary, and provide a spit basin for the patient. EMS treatment does not include packing the nares and nasal cavity with gauze.

There are two common nosebleed questions that students ask EMS instructors. First, should you apply ice to the patient’s forehead, neck or upper lip? Ice packs do not help.3,11 A study on the efficacy of ice packs in the management of epistaxis found no significant effects on blood flow to the nose after applying ice packs to the patient’s neck. A cool compress or ice pack applied to the nose might help reduce swelling if the cause of bleeding is from trauma or a foreign-body obstruction. Do not apply ice directly to the skin of the nose.

The second question: My high school gym teacher told us to apply pressure to the lip, forehead or back of the neck. Does that work?

Applying direct pressure by pinching the nostrils at the source of the bleed is the most effective treatment for epistaxis.

If an unconscious patient has a nosebleed, it is likely that blood is either being swallowed, which could lead to vomiting or cause an upper airway obstruction. Frequent suctioning will be necessary to keep the airway clear. Follow local protocols for airway control.

Quick-clot powders are being marketed for prehospital hemorrhage control. Figure 1 shows the application of one product, Nosebleed QR, which is an over-the-counter topical powder. Consult with medical control before adding these products to your jump kit.

If bleeding is prolonged or copious, hypovolemia can become a complication. Any signs and symptoms of hypovolemia, such as increased pulse and respirations, changes in mental status, and pale, cool, clammy skin, point to significant blood loss.3 Monitor oxygen levels with pulse oximetry and be prepared for the patient to vomit. Initiate fluid resuscitation following local protocols and monitor cardiac rhythm.5

If severe bleeding or nose and facial trauma compromise the patient’s airway, you need to establish airway control. Significant trauma and severe bleeding can make it difficult to visualize intubation landmarks, obscure the vocal cords and complicate controlling the tongue with the laryngoscope. Follow local protocols for inserting an endotracheal tube with rapid sequence intubation. If blood is refilling the hypopharynx faster than you can suction, digital intubation or a surgical airway may be indicated.

Follow local protocols for administering medications to patients with nosebleeds, breaks or obstructions. If the patient complains of nausea from swallowing blood, an antiemetic like promethazine (Phenergan) is useful to reduce nausea symptoms.7 Pain control for a patient with a nasal fracture can have comforting and sedating effects.

Obstructions

Some foreign bodies will be obviously visible, either protruding from the nose or visible in the nare. Those that have been pushed further back into the nasal cavity may not be visible.10,12

A treatment priority is to identify the type, size and location of the object. The location of the object and substance involved will determine urgency.10 Objects that contain chemicals, like watch or game batteries, can allow chemicals to leak and burn tissue. Food objects may expand in size and become more painful and damaging over time.

During assessment, the patient is most likely to complain about pain and irritation on the side with the obstruction. The fragile tissues of the nasal cavity are easily abraded by objects. If the object has been in the nose for a while, there might be a foul-smelling discharge. The complication of most concern is if the object is able to fully pass through the nasopharynx and cause an obstruction of the trachea or esophagus.

It is natural for children to be curious about exploring their nose, but they might be embarrassed to answer your questions. Establish rapport with the child and ask nonjudgmental questions.10 Do not probe the nose with a cotton swab at the risk of pushing the object in further and causing additional damage.12 Encourage the patient to breathe through his/her mouth to keep the object from being further inhaled.

Treatment, especially for older children and adults, might start by advising the patient to exhale, blow their nose or sneeze while occluding the unobstructed nostril.10

Emergency removal of a foreign-body obstruction from the nose depends on the location, visibility of the object and urgency for removal. If it protrudes from the nose, gently withdraw with your fingers, tweezers or gentle suction.10 Do not advance the suction tip beyond the opening. Avoid anything that might push the object further into the nasal cavity or cause it to pass through the nose and create an airway obstruction.

On-scene removal is best reserved for objects that are easily visualized, of known size and surface texture, and have not advanced past the nostrils. Do not blindly explore with tweezers or suction, which can cause damage to delicate nasal cavity tissues. Save more complex exploration and removal for the controlled environment and lighting of the emergency department.

If the object resists movement, or there is a sharp increase in pain, stabilize the object in place, as necessary, and transport the patient for evaluation.

If nasal bleeding is caused by foreign-body obstruction, pinching the nostril might be too painful or ineffective. Have the patient sit upright with a basin or towel to spit into; discourage them from swallowing blood that drains into the mouth.

If the object is removed on-scene, determine the need for transport by consulting with the patient, or his parents or guardian, and medical control. Transportation to a hospital might be indicated if there is continuing drainage, uncontrolled bleeding or persistent pain after removal.10 Even though the main object has been removed, smaller pieces might remain in the nasal cavity.

Summary

Nosebleeds from a break and/or obstruction can result in life-threatening problems. The nose is the airway opening that warms, humidifies and filters air. Control epistaxis with well-aimed direct pressure for 10–15 minutes. Nasal fractures, which are the most common facial fracture, can be the outward sign of skull fracture, brain injury or c-spine impairment, and may pose a threat to the airway and breathing. The greatest concern of a nose obstruction is aspiration. n

References

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11. Teymoortash A, Sesterhenn A, Kress R, et al. Efficacy of ice packs in the management of epistaxis. Clinical Otolaryngology 28(6):545–547, December 1, 2003.
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