Index

Background

Epistaxis can be classified into 2 main groups:

Classification	Implicated vessel	Description
Anterior epistaxis	Kiesselbach plexus (Little's area of the anterior nasal septum)	80-95% cases
Posterior epistaxis	Branches of the sphenopalatine artery in the posterior nasal cavity	Usually in older people

Local causes of damage to blood vessels:

Trauma (e.g. nose picking, nasal fractures, septal perforation)
Nasal oxygen therapy
Inflammation (e.g. chronic sinusitis, nasal polyps, allergic rhinosinusitis)
Topical drugs (e.g. cocaine, decongestants, corticosteroids)
Vascular causes (e.g. HHTHereditary haemorrhagic telangiectasia, GPAGranulomatosis with polyangiitis)
Post-operative bleeding
Tumours (e.g. angiofibroma, squamous cell carcinoma)

General causes of vessel damage (non-specific):

Atherosclerosis
Clotting disorder (e.g. vWDVon Willebrand disease, haemophilia, leukaemia, thrombocytopaenia)
Anti-thrombotic drugs (antiplatelet and anticoagulants)
Excessive alcohol consumption
Environmental factors (temperature, humidity, altitude, exposure to irritants)

Guidelines

Clinical diagnosis. Laboratory investigations are not usually required unless an underlying cause is suspected.

Examine both nasal passages
Ideally with a nasal speculum and adequate lighting

Features suggestive of a posterior bleed:

Bleeding is profuse
Bleeding from both nostrils
Bleeding site cannot be identified on speculum examination
Bleeding first started down the throat

Immediate transfer to A&E
Consider tranexamic acid 1g PO while awaiting hospital transfer to major haemorrhage

If posterior epistaxis is suspected → admit to hospital immediately

Otherwise, manage as following:

Steps	Management	Description
Step 1	First aid measures	Sit up + tilt forward (avoid lying down, unless feeling faint) Pinch the soft cartilaginous part of the nose firmly for 10-15 mins without releasing the pressure Keep the mouth open and breathe through the mouth
Step 2 (if bleeding did not stop after 10-15 mins of first aid)	Nasal cautery or nasal packing	If bleeding point is identifiable → silver nitrate nasal cautery (avoid in younger children) If ineffective → nasal packing If bleeding point is NOT identifiable → nasal packing + admit to hospital If nasal cautery and nasal packing are not available in primary care → admit to hospital
Step 3 (if the above failed)	Secondary care management	Options include: Endoscopic assessment and electrocautery Formal packing Radiological arterial embolisation Surgical intervention (e.g. diathermy, septal surgery, arterial ligation, laser treatment)

Steps

Management

Description

Step 1

First aid measures

Sit up + tilt forward (avoid lying down, unless feeling faint)
Pinch the soft cartilaginous part of the nose firmly for 10-15 mins without releasing the pressure
Keep the mouth open and breathe through the mouth

Step 2 (if bleeding did not stop after 10-15 mins of first aid)

Nasal cautery or nasal packing

If bleeding point is identifiable → silver nitrate nasal cautery (avoid in younger children)
- If ineffective → nasal packing

If bleeding point is NOT identifiable → nasal packing + admit to hospital

If nasal cautery and nasal packing are not available in primary care → admit to hospital

Step 3 (if the above failed)

Secondary care management

Options include:

Endoscopic assessment and electrocautery
Formal packing
Radiological arterial embolisation
Surgical intervention (e.g. diathermy, septal surgery, arterial ligation, laser treatment)

Potential complications of nasal cautery:

Septal perforation
Therefore avoid performing on both sides of the septum

Potential complications of nasal packing:

Sinusitis
Septal haematoma / abscess
Pressure necrosis
Toxic shock syndrome

If the bleeding stops with first aid measures:

Consider Naseptin^®(chlorhexidine and neomycin) cream - QDS for 10 days
If allergic to neomycin / peanus / soya → consider mupirocin nasal ointment

If the bleeding stops with nasal cautery:

Dab the cauterised area with a clean cotton bud
Apply Naseptin^®(chlorhexidine and neomycin) cream - QDS for 10 days
Observe the patient for 15 min to ensure bleeding is controlled
Advise the person to avoid blowing their nose for a few hours

After nasal packing:

Admit for observation

Advise the person on first aid measures to control bleeding during an acute episode

Determine if there is an underlying cause for epistaxis:

Consider FBC
If < 2 y/o → consider referral to a paediatrician as an underlying cause is likely

If there is unlikely an underlying cause of the epistaxis:

1st line: topical Naseptin^®(chlorhexidine and neomycin) cream QDS for 10 days
- If allergic to neomycin / peanus / soya → consider mupirocin nasal ointment
2nd line: nasal cautery

References

NICE CKS Epistaxis (nosebleeds)

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Epistaxis (Nosebleeds)

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Epistaxis (Nosebleeds)

Background

Classification

Causes

Guidelines

Investigation and Diagnosis

Management

Acute Epistaxis

Haemodynamically Unstable

Stable

Complications of Treatment

Management After Resolution

Recurrent Epistaxis

References

Original Guideline

Background Information

Definitions and Classifications

Guidelines

Red Flags

Investigation and Diagnosis

References

Original Guideline