A student walks into the school health office leaving a bloody trail behind them and making a mess all over themselves and the floor.  Other students are horrified and panic is spreading.  In some cases, the student isn’t even sent to the health office but the school nurse is instead called to a “bleeding emergency”.  Dropping everything, the school nurse rushes to the call to find a perfectly well-appearing student, head tilted back, nose bleeding.  Feelings of relief and frustration come over the school nurse as yet another episode of epistaxis induces panic and pandemonium amongst students and faculty.

Despite being very common in school-aged children and in the vast majority of cases, self-limiting and not cause for concern, the bright red blood produced from a nosebleed can often appear massive in amount and results in the alarm and distress that regularly accompanies nosebleeds in the school setting.  By providing education to the school community, familiarizing yourself with real epistaxis emergencies, and establishing a nursing care plan and emergency action plan for students with bleeding disorders, the school nurse can promote a safe and calm response to nosebleeds at school.

Epistaxis is any loss of blood from tissue in the nose.  Due to a convergence of a number of different arterial branches called Kiesselbach’s plexus in the anterior nasal septum, there is a very rich blood supply in the nose, critical for sinus health.  Because of its proximity to the entrance of the nasal cavity, the fragile vessels at the front of the nose are susceptible to temperature extremes, moisture variations and instances of trauma.  This is the site of 90% of nosebleeds, particularly for children whose fingers have very easy access to the area!

Keeping calm

Provide reassurance to students and staff that nosebleeds are generally harmless and blood spreads easily so what often looks like a lot of blood is, in fact, very little.  Teach appropriate interventions including continuous compression (10 minutes) of the nares while sitting upright, leaning forward slightly and encouraging the student to breathe through their mouth.  Consider placing a cold compress on the bridge of the nose to constrict the blood vessels.  If, after 10 minutes the bleeding persists, damp gauze or other packing can be inserted into the nostril that is bleeding and the nares should be gently pinched for another 10 minutes.  Make sure classrooms are stocked with tissues and teachers have all the supplies they need to safely (and calmly!) support nosebleeds at school.

Cause for Concern

Over 99% of nosebleeds stop after 10 minutes of direct pressure has been applied.  If the bleeding hasn’t stopped after 20-30 minutes of direct pressure, the student may need emergency care.  For students with bleeding disorders including von Willebrand disease or hemophilia, and for students with abnormal nasal vasculature, as in HHT syndrome, nosebleeds can pose a significant problem.  In these cases, both a nursing care plan and emergency action plan should be on file and reviewed with school staff to ensure the student is safely supported in the event of a nosebleed.  Any student that feels weak, faint or ill with a nosebleed or when a more serious injury to the nose or head trauma is suspected, further medical evaluation is necessary.  Additionally, if new-onset nosebleeds are occurring frequently or there is new bruising or bleeding reported from other parts of the body (gums, stool, urine, etc), the student should be referred to their primary care provider.

Prevention Measures

It can be helpful to provide the school community with suggestions to help prevent recurrent nosebleeds including:

• Use a humidifier at home if the air is dry
• Teach kids how to gently blow their nose, encourage no picking and keeping fingernails short
• Consider OTC saline nasal spray or gel to keep the nares moist
• After a nosebleed, petroleum jelly can be applied BID for up to a week to prevent rebleeding
• If allergies are the suspected cause, discuss allergy treatment plans with primary care provider

Nosebleeds can be scary for students and school staff, sometimes leading to unnecessarily frantic calls or visits to the school nurse. By providing reassurance that nosebleeds are very common and usually not dangerous, sharing appropriate response and treatment guidelines, stocking useful supplies, preparing for actual epistaxis emergencies and recommending prevention measures, the school nurse can hopefully extinguish some of the nosebleed tumult and keep the calm amidst epistaxis episodes.