Death From a Severe Nosebleed

Image by RIs from Wikipedia

Attila the Hun was one of the most feared enemies of the Roman Empire. Ruler of the Huns from the year 434 until his death in 452, his empire stretched from Ural River to the Rhine River and from the Danube River to the Baltic Sea.

Although there are numerous theories as to how he died, the conventional account is that he died from a severe nosebleed on his wedding night.

Some may scoff that only people in historical times die from nosebleeds... but it unfortunately still even happens in the present.

Yes... a life-threatening nosebleed can be fatal whether a historical figure like Attila or a modern day individual. And I am talking in people who are otherwise completely healthy (no hemophilia, ITP, Osler-Weber-Rendu, etc).

Indeed, a Seattle lawyer died from a nosebleed in 2008.

Two British individuals died from a nosebleed in 2008 and in 2011.

And those are just the ones that are reported in the media.

It is estimated that in 1999, 4 out of 2.4 million deaths in the United States was due to a nosebleed [link].

Fatal nosebleeds in a normal healthy individual are almost always due to an arterial bleed, notably the sphenopalatine artery located in the back of the nose. Other less common fatal nosebleeds may be attributable to the ethmoid arteries located in the top of the nasal cavity.

Treatment of such life-threathening nosebleeds depends on the situation, but may include:

• Nasal packing
• Embolization
• Surgical

Cautery as shown in the video below is rarely successful.

Sources:
Man died after suffering two-hour nose bleed. Mirror News 11/24/11

Man Dies From Severe Nosebleed. ABC News 12/2/11

Woman sues hospital after her husband dies of nosebleed. KOMONews 5/4/13

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Video of How Nasal Cauterization for Nosebleeds Is Performed (Silver Nitrate and Electric)

I made a nosebleed video a few years ago that was roundly criticized for being poorly made. The biggest complaint was the loud background music. As such, I have made a new video that I feel addresses many of the shortcomings levied on the original video. I also added additional footage of what different types of nosebleeds look like as well as adding bipolar cauterization as another method of cautery other than silver nitrate.

Check the new (upgraded) video!

For more info about nosebleeds, click here.

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Do Nosebleeds Cause Stool Blood Tests to Become Positive?

As a general rule, an ordinary nosebleed will not cause a screening stool blood test (hemoccult or guaiac) to come back positive.

However, if the nosebleed is bad enough to consider going to the emergency room... and you are swallowing a lot of it... only than will it be likely that such stool tests will come back positive for blood.

To be precise, such stool tests turn positive only if there's at least 2+ teaspoons of blood leaking into the digestive system everyday (or swallowed from a very bad nosebleed).

Of course, there are MUCH more sensitive tests out there to determine if there's blood in the stool including heme-porphyrin or immunochemical tests, but have a high false-positive rate.

From an ENT perspective, immunochemical testing is interesting because this test uses antibodies to detect human globin epitopes which get digested in the stomach... so if there's a question of whether a patient's anemia is due to nosebleed or a lower GI tract bleed (ie, colon), immunochemical stool testing can answer the question.

Just as an FYI, if the nosebleed is severe, it is likely that you will end up getting your nose packed.

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How Does Silver Nitrate Cauterize?

Silver nitrate is a chemical compound commonly used by ENT surgeons to stop nosebleeds as well as obliterate granulation tissue (found around tracheostomy stomas as well as intra-orally).

Medical silver nitrate is typically purchased as matchstick applicators and is usually found in combination with potassium nitrate (75% silver nitrate and 25% potassium nitrate).

When this applicator is combined with water (moisture inside the nose or blood):

AgNO3 + HOH  -->  AgOH + HNO3

Nitric acid (HNO3) is produced along with an insoluble precipitate silver hydroxide (AgOH) which produces the characteristic brownish-white discoloration that can stain clothing as well as skin.

Nitric acid also known as aqua fortis and spirit of niter, is a highly corrosive strong mineral acid and is what initiates the biologic "cauterization" action. It is also what causes a patient to feel a burning sensation when applied.

Silver nitrate applicator sticks can be purchased on Amazon.com.

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Foley Catheter to Stop Nosebleed???

A foley catheter, as shown above, is normally used to drain urine from the bladder, but it can also be used to stop severe nosebleeds... albeit under dire circumstances and when there is no other suitable alternative.

Normally, for a severe nosebleed, the nose can be packed with a tampon like packing material. The packing material I like best is a rapid rhino which is illustrated below.

Nasal packing like the rapid rhino exerts pressure within the nose to the point whereby the bleeding stops (like putting direct pressure on a leg wound to stop bleeding).

However, if there's no nasal packing around and the person is having a severe life-threatening nosebleed which almost always is due to a posterior bleeding site, and all you have is a foley catheter...

Use the foley catheter!

Insert the foley through the nose on the side that is bleeding just like an naso-gastric tube...

Once inserted so the catheter can be seen in the back of the mouth, inflate balloon with saline. After inflating the foley balloon, pull the foley catheter back out as if to take the foley catheter out. However, given the foley balloon is inflated, it will snug up in the back of the nose such that it can't be taken out.

Pull on the foley catheter with enough pressure to equal the amount of pressure desired to stop the nosebleed. Once at the correct tension, clamp the foley at the nasal entrance to prevent it from falling back into the nose. Packing with gauze in the front of the nose can also be performed to prevent bleeding coming out the front.

Of course, this is a TEMPORARY measure and should be replaced as soon as possible with appropriate nasal packing material.

But, it certainly works when in a bind.

Here's a video showing how cauterization can stop nosebleeds.

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How Does Nasal Packing Stop Nosebleeds?

It is not unusual for an ENT or an Emergency Room physician to see a patient with a very bad nosebleed... the kind that can potentially be life-threatening given how much active bleeding is occurring.

In these situations, nasal packing is the fastest and best way of stopping the nosebleed.

For any type of active bleeding, direct pressure tamponades the bleeding thereby stopping it... whether it be a stab wound to the leg or a bad nosebleed. In essence, direct pressure exerts a certain amount of pressure that exceeds the blood pressure preventing blood flow. The corollary being if the amount of direct pressure being exerted is LESS than the blood pressure, bleeding will still occur.

With nasal packing, pressure is exerted by the packing material and pressed against whatever the bleeding source is within the nose.

My personal favorite packing material is called the rapid rhino made by Arthrocare (I have no financial ties to the company). It is in essence a balloon covered by a bio-compatible self-lubricating fabric. This device is inserted into the nose in a deflated state. 

Once fully inserted into the nose, it is than inflated using a standard syringe. Enough air is inflated into the device such that the pressure exerted by the balloon exceeds the blood pressure of the vessels within the nose.

The key point here is that enough pressure must be exerted by the balloon device. If the patient's blood pressure exceeds the balloon pressure, bleeding will still occur and MORE air must be pushed in. As such, in patients with high blood pressure, more air must be inflated into the balloon device to stop a nosebleed compared to a patient with low blood pressure.

So, here is what it looks like to insert a rapid rhino nasal packing.

Step 1: After hydrating the fabric, the nasal packing is placed at entrance of nose.

Step 2: Nasal packing is fully inserted into the nasal cavity.

Step 3: The nasal packing balloon is than inflated with enough air pressure to stop the nosebleed.

Obviously, blood pressure must also be controlled and the nasal packing can be removed in about 3 days for patients not taking any blood thinners or anti-coagulants (coumadin, plavix, ticlid, pradaxa, aspirin, ibuprofen, etc). For those on such medications, packing may need to be kept in place longer.

For more information about nosebleeds.

Watch a video regarding how cauterization can stop nosebleeds.

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Bacon Can Stop Nosebleeds! No joke...

When I saw this research, I had to re-read it to believe it... Nasal packing with good-old fashioned bacon stops nosebleeds!!!

Yes... you heard me correctly... and it was actually published in a reputable ENT journal in Nov 2011. AND, it was conducted here in the USA (Detroit, Michigan).

"Cured salted pork crafted as a nasal tampon and packed within the nasal vaults successfully stopped nasal hemorrhage promptly, effectively, and without sequelae … To our knowledge, this represents the first description of nasal packing with strips of cured pork for treatment of life-threatening hemorrhage in a patient with Glanzmann thrombasthenia."

The current standard of care for nasal packing to treat nosebleeds is using synthetic hemostatic products that appear similar to tampons used for menstruation.

However, this publication in 2011 wasn't the first to document use of bacon for nosebleeds.

There have been reports on use of bacon since 1940 sporadically (see references below).

In this day and age of cost-cutting and finding cheaper alternatives, bacon is pretty much as cheap as one can go to address nosebleeds. Compare this to synthetic nasal packing which costs on upwards of $50 or more.

Read more about nosebleed management.

Another unusual nosebleed management includes the application of female hormone estrogen (vaginal premarin cream) to the nasal mucosa.

Traditional nosebleed treatment includes nasal emollient application, humidification, nasal cauterization, septoplasty, and eventually nasal packing.

References:
Nasal Packing With Strips of Cured Pork as Treatment for Uncontrollable Epistaxis in a Patient With Glanzmann Thrombasthenia. Ann Otol Rhinol Laryngol 2011;120:732-736.

Rendu-Osler-Weber Disease— Is Embolization Beneficial? Arch Otolaryngol. 1976;102(6):385.

GENERAL PRINCIPLES IN TREATMENT OF NASAL HEMORRHAGE. AMA Arch Otolaryngol. 1953;57(1):51-59.

USE OF SALT PORK IN CASES OF HEMORRHAGE. Arch Otolaryngol. 1940;32(5):941-946.

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