Article from September, 2016

Keeping Your Nose Out of Trouble

nosebleeds

Michael J. Manyak, MD, MED 92

A common problem on expeditions is the occurrence of nosebleeds. Many of us have faced this issue at some time in our lives and these usually can be controlled even in a remote area without access to advanced medical care. The nasal cavity has a lot of rather fragile blood vessels close to the surface of the nasal lining. Nosebleeds can be quite frightening but do not often indicate a serious medical problem.

Environmental conditions like low humidity, cold, and high altitude can precipitate nosebleeds. Nosebleeds certainly occur with trauma to the nasal area and also can be associated with upper respiratory tract infections where the nasal lining is inflamed. Nosebleeds can be a sign of high blood pressure that has risen out of control, particularly in older people. This is a medical emergency.

Medications that interfere with blood coagulation can contribute to the occurrence and severity of nosebleeds. The most common of these are aspirin and anticoagulants like warfarin (Coumadin). Chronic use of non-steroidal anti-inflammatory medication (NSAIDS) like ibuprofen or naproxen is also associated with delayed coagulation and increased risk of nosebleed. Use of these medications should be disclosed to the medical personnel on a trip in case of an emergency. Less commonly encountered are travelers with inherent bleeding disorders of coagulation. Most of these people are already aware of a bleeding tendency and should alert medical personnel on an expedition about this condition, particularly if the environment increases conditions for a nosebleed. Normally they are not necessarily more prone to nosebleeds but if they occur, they can be difficult to control.

Nosebleeds are classified as anterior or posterior depending on the intranasal site of bleeding. Anterior nosebleeds originate from the lining of the nostrils, frequently the nasal septum (cartilage that separates the nostrils), and are by far the more common and more easily managed. Blood typically drains out from the nostrils with an anterior bleed.

Posterior nosebleeds are characterized by blood draining back into the throat causing coughing, swallowing of blood, and possibly choking or vomiting. The blood vessels in a posterior bleed are usually larger than those in an anterior bleed. Posterior bleeds are more difficult to control and someone with a posterior nosebleed usually needs to be evacuated.

PREVENTION AND TREATMENT

Prevention of nosebleeds is helped by lubricating (with Vaseline) the inside of the nose in dry climates or at high altitude. Nasal saline drops are also useful for lubrication. Do not use vaso-constrictive nose drops because vasodilation of vessels in the nasal lining after stopping the drops can lead to an increased risk of bleeding.

If you have high blood pressure, make sure it is under control before departure. If you are taking daily aspirin, non-steroidal anti-inflammatory medication, or are on anticoagulation medication, be sure to notify the medical personnel or expedition leader on your trip.

For anterior nosebleeds, start by having the victim sit up and firmly press the nostrils together for about 15 minutes; then release to check if bleeding has stopped. If not, pack both nostrils with gauze if available or else use toilet tissue or other clean tissue. Cotton balls and Vaseline gauze are useful for packing. Pack tightly and have the patient hold the nostrils for another 15 minutes and then gently remove the packing. If the nose is still bleeding, repack the nostrils and leave for a couple of hours before attempting gentle removal. Packing can be preceded by application of a nasal spray (Afrin or Neo-Synephrine) that causes vasoconstriction.

Persons with suspected posterior nosebleeds need to be evacuated. These are very difficult to treat without medical assistance and likely require posterior nasal packing, not done easily in a remote location. However, if evacuation is delayed and there is a Foley urinary balloon catheter in the medical kit, the catheter can be inserted into the posterior nasal chamber after lubrication. Inflate the balloon with 10 to 15 ml of saline or water and gently pull forward so that the balloon locks into place. The catheter should be taped in place to maintain the pressure on the posterior location. The pressure from the balloon will help stop bleeding. Leave it in place until medical assistance is available.

Reversal of anticoagulant medications is not easy and should only be attempted under guidance of medical personnel. Aspirin and NSAIDS cannot be reversed and neither can some of the more recent anticoagulation medications. However, direct pressure often will work despite anti-coagulation.

One last word of caution. Pick both your friends and your nose carefully!

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This article was published in The Explorers Journal

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journal
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