Question about nose bleeds

[Diver0001]

I am an instructor and I occasionally get a student who is prone to nose bleeds while diving.

The most recent example of this was an advanced student who had small amounts of blood in his mask after every dive. He experienced no pain or discomfort and wanted to continue with the training, which I did. I also told him that I found it odd and asked him to go see an ENT to get it checked out, which he did not.

After the fact, I wonder if I should have halted his training to force him to go see an ENT.

The question for the medical experts is this: At what point, as an instructor, would it be advisable to halt the training because of nose bleeds? If they're in pain, it's clear, but what if they're NOT in pain?

Any advice is welcome.

R.

 

[TSandM]

Well, the first thing I would do with someone who had bleeding in their mask after a dive is very carefully go through equalization with them, and have them demonstrate what they are doing, and have them practice on land. I think the majority of nosebleeds are caused by trauma from people waiting too long to equalize, and then having to use excessive force to get it done.

If someone has repeated bleeding, either they're not getting the idea, or there is something abnormal in their nose or sinuses. This can be as simple as someone with allergies who has irritated mucosa, or someone with nasal polyps, or somebody with sinus disease who isn't equalizing the sinuses (although that would typically be painful). Someone who is bleeding after every dive should, I think, be evaluated by a good ENT doc.

If it's scant bleeding or just pink liquid in the mask, and the patient is asymptomatic (no pain, no ringing in the ears, no muffled hearing) I think it's reasonable to allow them to attempt another dive.

 

[doctormike]

Absolutely, what she said.

Most epistaxis (fancy name for nosebleeds) happens from sinus barotrauma, since that space is connected to the nasal airway by a small, easily obstructed passageway. Sudden explosive decompression usually happens on ascent. The bleeding itself may not be such a big issue (insert shark dive joke here), but it is a sign of improper equalization which can lead to bigger sinus related problems (such as injuries to the space around the eye, etc...).

Sometimes, there is just a prominent vessel on the nasal septum that can be cauterized in the office.

And I will take the opportunity to tell people how to stop a nosebleed (most people do this wrong). Just pinch the nostrils together. Since the vast majority of nosebleeds come from the septum (wall in the middle of the nose) right up front, this will usually stop it. Pinching the bridge of the nose does virtually nothing, and leaning your head back does very little to change the blood pressure in this area, but I guess it is better than leaning over forwards.

Mike

 

[Bubbletrubble]

To expand further on what's already been discussed...

While stopping a nose bleed, there are practical reasons for leaning slightly forward as opposed to tilting the head back. Leaning forward will prevent the blood from trickling down the diver's throat. Blood going in this direction can cause throat irritation, gagging, nausea or possibly result in aspiration of blood -- all things one should avoid.

In addition to sinus barotrauma, allergies, and sinus disease (all of which occur with some frequency in divers), other predisposing factors for nose bleeds include: clotting disorders, "mechanical" trauma (nose picking), high blood pressure, alcohol abuse, and blood-thinning meds. Of course, these are all things that a physician would take into consideration when evaluating a patient with nose bleeds. Just something to keep in mind...

 

[TSandM]

Just a word about getting nosebleeds to stop . . . Upright posture, leaning slightly forward as Bubbletrubble describes, is important. Lying down will raise venous pressure and encourage continued bleeding.

Direct pressure is the key to getting most nosebleeds to stop. Direct pressure needs to be applied to the SOFT portion of the nose. Many people squeeze on their nasal bones, which are incompressible, and this really doesn't accomplish anything. Squeeze below the bones . . . and do it for AT LEAST five full minutes before you release the pressure to check if the bleeding is continuing. Many people squeeze for thirty seconds and release to check, and you reset the clock each time you do that. People come into the ER and tell me they've been holding pressure for twenty minutes, when we can get the bleeding stopped in two -- IF we don't release the pressure.

If you are prone to nosebleeds, carry Afrin or Neo-synephrine (assuming you don't have a contraindication to those medications). Blow the clots out of your nose with firm, rapid exhalations, and then give two squirts of medication in each nare, and begin your five minutes. This will stop the vast majority of diving-type nosebleeds. (It won't stop posterior bleeds, which are usually related to head and neck pathology or uncontrolled high blood pressure, but those are not usually diving-related incidents.) If you have an ice pack, you can add that to the mix (externally, and only if it doesn't interfere with holding effective pressure.)

Rare is the nosebleed in a healthy person who is not on blood thinners that cannot be stopped using these simple techniques.

 

[doctormike]

OK, to clarify -

The issue about leaning backwards vs. forwards was not meant to apply to epistaxis while diving. Yes, it would be better to avoid having blood run into the throat underwater, but I was referring to regular bleeding above the surface, in which leaning far forwards will increase blood pressure in the nose.

The point was that vast majority of nosebleeds come from the front of the septum, and that the pressure from pinching the nose is far beyond any pressure differential from head position. But I guess it's a matter of degree...

TSandM gives a good description of what it takes to get nosebleeds to stop by compression.

 

[BTravlin]

I often got nose bleeds after my first couple dozen dives. Went to the ENT and he cauterized a few vessels close to the surface of the skin. No nose bleeds since then. Have the student see the ENT.