


Very common
Usually self limiting
Rarely massive bleeding can be fatal

To understand the causes and predisposing
factors

To consider assessment and management

To review complications



Is bleeding from the nose caused by damage
to blood vessels of nasal mucosa
Anterior (80-90%), Little’s area anterior nasal
septum – Keisselbach plexus of vessels
Posterior from branches of sphenopalatine
artery in posterior nasal cavity




60% of population
6% seek medical attention
Peaks – 2-10 years
greater than 45 years – posterior
epistaxis more common in older people
Under 2 years rare and may be associated
with injury or underlying serious illness





Nosepicking
Nasal fractures
Septal ulcers / perforation
Foreign body
Blunt trauma e.g. falls



Infection
Allergic rhinosinusitis
Nasal polyps

Topical drugs-cocaine, nasal decongestants

Vascular –hereditary haemorrhagic
telangiectasia
Wegeners granulomatosis

Post-operative – ENT, max fax, ophthalmic


Benign tumours – angiofibroma
Malignant tumours – squamous cell

Nasal oxygen






Hypertension
Atherosclerosis
Increased venous pressure from mitral
stenosis
Alcohol
Environmental – temperature, humidity,
altitude






Thrombocytopaenia
Platelet dysfunction
Leukaemia
Haemophilia
Anticoagulant drugs
Antiplatelet drugs e.g aspirin, clopidogrel



Most self-limiting and do not require medical
treatment
Transfusion unusual
Massive bleeding rare but can be fatal


ABC
resuscitation as required



Lean forward (decreases blood flow through
nasopharynx)
Open mouth, spit blood into bowl, minimises
swallowing
Pinch soft part of nose for 10-15 minutes
CONTINUOUSLY






Duration
Which nostril
Estimated blood loss
Any home management / packing
Previous epistaxis and management
PMH –likely underlying causes



Surgery
Trauma
Symptoms suggestive of tumour
◦
◦
◦
◦
Nasal obstruction
Rhinorrhoea
Facial pain
Facial numbness, double vision



Drugs
FH bleeding disorders
environmental






ABC
General examination
Local examination
Light source and nasal speculum
Get patient to blow nose ( dark blood or clots
likely to be old)
Look for bleeding point ( if bleeding stopped
, small red dot < 1mm)

Profuse bleeding from both nostrils with no
visible bleeding point on speculum
examination suggests posterior bleed



FBC if heavy or recurrent bleeding or clinically
anaemic (often not required)
Coagulation – if on warfarin or bleeding
diathesis suspected
Group and save / cross match - if bleeding
heavy, shock, severe anaemia




Naseptin (chlorhexidine and neomycin) qds
for 10 days
Avoid in peanut allergy – use mupirocin
instead
Reduces crusting and vestibulitis
Very useful in young children as cautery
inappropriate





Use if first aid unsuccessful, not for young
children
Need appropriate expertise and equipment
Blow nose
Anaesthetic spray preferably with
vasoconstrictor (eg lignocaine and
phenylephrine)
Allow 3-4 mins for anaesthetic to work




Identify bleeding point
Apply silver nitrate stick to bleeding point for
3-10 seconds until grey-white colour
develops
Only one side of septum to avoid septal
perforation
Avoid touching area not requiring treatment



Dab cauterised area with clean cotton bud to
remove chemical or blood
Naseptin or mupirocin cream
Self care advice






Avoid blowing or picking nose
Avoid heavy lifting
Avoid strenuous exercise
Avoid lying flat
Avoid alcohol and hot drinks ( cause
vasodilation)
If further bleeding unresponsive to first aid
measures, return to ED

If bleeding not controlled
Local anaesthetic and vasoconstrictor

Nasal tampon (merocel)

Inflatable packs (rapid rhino)


Impregnated ribbon gauze – needs specific
expertise





Position sitting forward mouth open
Secure pack to cheek
Check no pressure on cartilage around nostril
Check oropharynx for bleeding, may need to
pack both nostrils
Admit ENT





Sinusitis
Septal haematoma /abscess (from traumatic
packing)
Pressure necrosis (from excessively tight
packing)
Toxic shock syndrome (prolonged packing)
Airway obstruction





Uncontrolled bleeding
Posterior bleeding
Nasal pack
Significant comorbidities clotting disorder,
anaemia
Recurrent with high risk of underlying cause





Formal packing
Endoscopy and electrocautery
EUA and surgical intervention e.g. Arterial
ligation
Radiological arterial embolisation
IV or oral tranexamic acid





History and examination
Consider underlying cause
Refer children under 2 years for further
investigation
Manage with topical antiseptic or nasal
cautery
Refer if epistaxis not settled or high risk of
serious underlying cause

Reference – NICE 2010






ABC and resuscitation plus first aid measures
History – and consideration of underlying
cause
Examination local /general
Investigation where appropriate
Management
Referral to ENT