Epistaxis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

active epistaxis: major haemorrhage

1st line – follow local major haemorrhage protocol

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1st line –

follow local major haemorrhage protocol

After assessing the patient using the Airway, Breathing, Circulation (ABC) approach, if the patient is haemodynamically unstable:[6][22]

Call for help immediately so that you can start resuscitation urgently and also, if possible, apply nasal first aid.
- Signs of acute hypovolaemia might include tachycardia, syncope, or orthostatic hypotension.[10][16]
  - Tachycardia may be due to hypovolaemia, anaemia, anxiety, or pain (from packing placement or cautery)
  - See Shock.
- The British Society for Haematology defines major haemorrhage as either:[23]
  - Acute major blood loss associated with haemodynamic instability (e.g., heart rate >110 beats per minute and/or a systolic blood pressure <90 mmHg), or
  - Bleeding that appears controlled but still requires 'massive' transfusion, or is significant due to the patient’s clinical status, physiology, or response to resuscitation therapy.
- Manage major haemorrhage according to your local major haemorrhage protocol.[23]
Seek senior or ENT help early in children and elderly patients with severe bleeding as these patients may require aggressive resuscitation and specialist input.

Seek early case-specific guidance from haematology for any patient who:[6]

Is on anticoagulation
Has a coagulopathy
Needs blood transfusion.

Practical tip

Visual quantification of blood loss, either from the patient’s history or blood-stained clothing, is unreliable and blood loss can be underestimated by both medical and non-medical staff.[10]

Protect yourself from the high risk of contamination associated with epistaxis due to direct bleeding into the airway and the increased likelihood of droplet spread. Follow your local protocol, but as a minimum, you should don the following:[16]

Gloves
Mask
Visor (face shield)
Lab coat.

Plus – resuscitation and supportive care ± admission

Consider – nasal first aid

Consider – tranexamic acid

active epistaxis: no major haemorrhage

1st line – nasal first aid

Back

1st line –

nasal first aid

After assessing the patient, start first aid measures to control bleeding from the nose if the patient is haemodynamically stable.[6]

Ask the patient to lean forward but remain upright and firmly pinch the soft part of the nose compressing both nostrils (and possible anterior bleeding sites) for at least 10 minutes.[6][16]
Encourage the patient to spit out, rather than swallow, any blood passing into the throat (blood is irritating to the stomach and may make the patient nauseous).
Provide an oral ice pack.[6]
- Alternative, practical options include an ice cube for the patient to suck, or applying an ice pack directly to the nose to reduce nasal blood flow.

Children

Children should sit comfortably, possibly on their parent’s lap so that the parent can assist if necessary with firm compression of the lower part of both nostrils for at least 10 minutes. Encourage the child to breathe through their mouth.

Practical tip

Use a swimmer’s nose clip as an alternative technique to apply external pressure on the nostrils.[30]

Consider – vasoconstrictor ± local anaesthetic nasal spray

Back

Consider –

vasoconstrictor ± local anaesthetic nasal spray

Additional treatment recommended for SOME patients in selected patient group

If nasal first aid doesn’t stop the bleeding, clear blood using suction, gentle nose blowing, or forceps (be careful not to injure the nasal mucosa). Then apply a topical vasoconstrictor (e.g., oxymetazoline) ± local anaesthetic (e.g., lidocaine) using any of the following methods:[10][26]

Spray
Soaked cotton wool ball
Pledget.

Consult local protocols for appropriate dose.

Practical tip

Use topical vasoconstrictors cautiously in patients who may experience adverse effects associated with peripheral vasoconstriction due to alpha-1-adrenergic agonists, for example those with:[10]

Hypertension
Cardiac disease
Cerebrovascular conditions.

Practical tip

Active bleeding may prevent proper evaluation, so mucosal vasoconstriction (decongestion) is helpful for diagnosis and management. If bleeding makes administration difficult, ENT doctors may attempt rapidly alternating nasal suction (or nose blowing) with intranasal spraying of oxymetazoline. This may exceed the typical dosage on the manufacturer's label, however active bleeding prevents absorption of much of the medicine, and these larger doses are routinely used without difficulty in nasal surgery via spray and on pledgets.

In practice, if bleeding is severe enough to preclude adequate assessment, avoid persisting too long with repeated alternations between suction and vasoconstrictor administration, and seek senior assistance.

Practical tip

A vasoconstrictor (decongestant) reduces blood flow, shrinks mucosal thickness, and increases nasal space should pack placement be required. This can reduce mucosal trauma and decrease secondary bleeding from disrupted mucous membrane.

Effective pack placement may be compromised if the procedure is painful. Prepare a mixture of lidocaine and oxymetazoline according to local protocols. Some clinicians simply remove the top from a spray bottle of oxymetazoline, add an equal volume of the lidocaine, and replace the top; however, consultant advice is recommended.

Next, saturate small neurosurgical pledgets or strips of cotton with the mixture and place them horizontally in the nose using bayonet forceps. Leave for 10 to 15 minutes while the patient compresses the nose if necessary.

Children

Use vasoconstrictors and anaesthetics with caution in young children, whether used to improve visualisation or to control the bleeding.[10][44]

Adequate nasal first aid usually stops epistaxis in children and examination of the anterior nasal cavity will commonly reveal either crusting of the anterior nasal mucosa or a visible vessel, which can be treated accordingly.

Plus – supportive care ± admission

Back

Plus –

supportive care ± admission

Treatment recommended for ALL patients in selected patient group

In addition to stopping the bleeding, monitor vital signs, supplement oxygen, obtain intravenous access, maintain the airway, and support breathing and circulation if required.

For more information on resuscitation, see Shock.

Allocate patients with epistaxis to an area of the emergency department where they can be observed closely, as dislodgement of blood clot may sometimes lead to catastrophic bleeding.[6]

Establish intravenous access

Establish intravenous access with a large-bore cannula at the same time as taking bloods, if indicated, in:

Older patients
Patients on anticoagulants
Haemodynamic compromise
Profuse bleeding
Bleeding >20 minutes.

Control raised blood pressure

The relationship between epistaxis and hypertension is complex and remains unclear.[10] There is a paucity of evidence and guidance on how and when to treat hypertension in patients with epistaxis.

In practice, if the patient is hypertensive, consider treatment according to hypertension guidelines and discuss a treatment plan with a senior colleague. See Assessment of hypertension.

Practical tip

In the absence of hypertensive urgency/emergency, US guidelines do not recommend routinely lowering blood pressure in patients with acute nosebleed. Interventions to acutely reduce blood pressure can have adverse effects and may cause or worsen renal, cerebral, or coronary ischaemia.[10]

Monitor blood pressure in patients with acute nosebleeds, and base decisions about blood pressure control on:[10]

The severity of the patient's nosebleed
The inability to control the bleeding
Individual patient comorbidities
The potential risks of blood pressure reduction.

If hypertension persists after severe epistaxis, request cardiovascular evaluation to screen for underlying hypertensive disease.[31]

Children

Seek an early senior or ENT opinion for any child with epistaxis that is severe or difficult to stop.

Consider admission

Decide whether your patient needs admission depending on what measures are needed to control the bleeding. In practice, if bleeding is controlled by first aid measures and topical agents, most patients can be discharged home.

If the patient presents in primary care, arrange for transfer to secondary care if any of the following factors exist:[29]

Epistaxis continues after nasal first aid and the facilities and expertise are not available for nasal cautery or packing
Epistaxis continues after nasal cautery and/or anterior packing (when appropriate expertise and facilities for cautery and packing are available in primary care)
A nasal pack is in place (even if bleeding has stopped)
The patient is on anticoagulant therapy (as a clotting screen will be needed)
The cause provokes concern (e.g., leukaemia/tumour)
An underlying cause is likely (e.g., conditions predisposing to bleeding, such as haemophilia or leukaemia)
Significant comorbidity (e.g., coronary artery disease, severe hypertension, severe anaemia)
Child aged <2 years
Frailty or old age.

Consider – safeguarding (in children)

ACUTE

persistent epistaxis despite initial measures

1st line – electrocautery or chemical cautery

Back

1st line –

electrocautery or chemical cautery

Consider cautery as first-line treatment for all acute epistaxis with obvious bleeding points, provided you are suitably trained and facilities allow.[6][10]

Only perform cautery:

On a visually identified bleeding point[6]
If you have been suitably trained.[6]
- If you can’t identify an anterior bleeding point, rigid endoscopy or microscopy (by a suitably trained and experienced practitioner) may be needed.[6]
- In practice, this may require referral to the ENT department, but do not wait for nasendoscopy; pack the nose as soon as possible to control the haemorrhage. The patient can then be referred to ENT for further assessment.

Clear blood in the front of the nose using suction, gentle nose blowing, or forceps.[26] A soft suction catheter is less likely to cause trauma to the nasal lining.

Practical tip

Do not cauterise both sides of the septum during the same episode; septal perforation may occur due to decreased perichondrial blood supply.[16]

Cauterise any visible vessel or localised area of bleeding in an adult patient with either one of:

Silver nitrate (75% strength) applied directly to the vessel[26]
- Apply for no more than 30 seconds in any one spot.[35]
- In practice, most junior doctors in the emergency department can become proficient in silver nitrate cautery.
Electrical cautery.[16][26]
- Electrocautery should be used in preference to silver nitrate cautery if a suitably trained clinician is available.[6][16] In the UK, this procedure is usually reserved for the ENT consultant and is generally performed in theatre.
  - The preference for electrocautery is based on lower treatment failure and recurrence rates, reduced need for nasal packing, and reduced rates of hospital admission when compared with silver nitrate cautery, although the quality of evidence for this is very low.[6]

Practical tip

What is meant by 'localised area' for nasal cautery has not been clearly defined. In practice, the aim is to identify an active bleeding point and precisely cauterise this area. If bleeding is brisk, ‘doughnutting’ may be an option: cauterise the four quadrants immediately surrounding the vessel to isolate the source and disrupt supply to the bleeding point. Do not cauterise a large area of the mucosa.

Cautery of a vessel that is not part of the Kiesselbach's plexus is not contraindicated, but bleeding from outside this area is rare.

Observe the patient for 15 minutes after cautery to ensure bleeding is controlled before discharge.

Practical tip

Silver nitrate (75%):

Is applied via commercially manufactured sticks or applicators (note that sticks may not be licensed for use on the face in some countries)
Degrades over time, so lack of activity may indicate the need to use fresher silver nitrate
Can stain the skin for weeks or months after nasal cautery if it is not dried adequately, or if there is subsequent nasal discharge.[36] After spraying or applying the vasoconstrictor ± anaesthetic, reduce the risk of staining by:[36]
- Drying the area with a cotton bud
- Applying silver nitrate from the outside edge of the bleeding point and continuing round in a spiral towards the centre of the bleeding point
- Drying around the area after application
- Protecting the skin in and around the nostril with antibiotic ointment or soft paraffin.

Children

In children, chemical cautery is preferred to electrocautery because electrocautery is more painful and requires a general anaesthetic.[16]

Consult a senior colleague if cautery is required.

Do not attempt cautery in a child aged <4 years as cooperation is unlikely and sedation is not recommended due to risk of inhalation of clots, packing, or local anaesthetic agents.

Consider – vasoconstrictor ± local anaesthetic nasal spray

Plus – supportive care ± admission

Back

Plus –

supportive care ± admission

Treatment recommended for ALL patients in selected patient group

In addition to stopping the bleeding, monitor vital signs, supplement oxygen, obtain intravenous access, maintain the airway, and support breathing and circulation if required.

For more information on resuscitation, see Shock.

Allocate patients with epistaxis to an area of the emergency department where they can be observed closely, as dislodgement of blood clot may sometimes lead to catastrophic bleeding.[6]

Establish intravenous access

Establish intravenous access with a large-bore cannula at the same time as taking bloods, if indicated, in:

Older patients
Patients on anticoagulants
Haemodynamic compromise
Profuse bleeding
Bleeding >20 minutes.

Control raised blood pressure

The relationship between epistaxis and hypertension is complex and remains unclear.[10] There is a paucity of evidence and guidance on how and when to treat hypertension in patients with epistaxis.

In practice, if the patient is hypertensive, consider treatment according to hypertension guidelines and discuss a treatment plan with a senior colleague. See Assessment of hypertension.

Practical tip

Monitor blood pressure in patients with acute nosebleeds, and base decisions about blood pressure control on:[10]

The severity of the patient's nosebleed
The inability to control the bleeding
Individual patient comorbidities
The potential risks of blood pressure reduction.

If hypertension persists after severe epistaxis, request cardiovascular evaluation to screen for underlying hypertensive disease.[31]

Consider admission

Consider whether your patient needs admission. Do not routinely admit.

Discharge patients if they are stable 4 hours after cautery.[6]

If the patient presents in primary care, arrange for transfer to secondary care if any of the following factors exist:[29]

Epistaxis continues after nasal cautery and the facilities and expertise are not available for anterior packing
The patient is on anticoagulant therapy (as a clotting screen will be needed)
The cause provokes concern (e.g., leukaemia/tumour)
An underlying cause is likely (e.g., conditions predisposing to bleeding, such as haemophilia or leukaemia)
Significant comorbidity (e.g., coronary artery disease, severe hypertension, severe anaemia)
Child aged <2 years
Frailty or old age.

Consider – treatment of underlying cause

2nd line – anterior nasal packing

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2nd line –

anterior nasal packing

Consider nasal packing if bleeding continues despite first aid measures, topical vasoconstriction ± local anaesthesia, and cautery (if available), if you can’t identify a specific bleeding point, or if there is bilateral bleeding.[26]

Ensure that you have been trained to use nasal packing.[6]

Insertion of an anterior nasal pack

Demonstrates insertion of an inflatable anterior nasal pack and a nasal tampon.

There are two types of packing:

Dissolvable, which in the UK is generally reserved for ENT departments
Non-dissolvable, which is available as compressed sponge and inflatable balloon tampons. Products commonly used in the UK are:
- Rapid Rhino^®, an inflatable coated nasal balloon catheter
- Merocel^®, an absorbent dry sponge tampon.

Practical tip

In practice, do not insert nasal packing in a patient with nasal polyps. If nasal first aid and cautery do not stop the bleeding, refer to ENT.

Non-dissolvable nasal packing

Depending on bleeding severity, pack the actively bleeding nostril or both nostrils.[26] Seek the advice of a senior colleague if bleeding is severe.

In practice:
- Different institutions will have experience with specific nasal packs. Follow local preferences.
- As epistaxis generally originates on one side, packing is usually unilateral.
- However, when the history and examination fail to identify whether the bleeding is from the right or the left, or when packing one nostril does not control the bleeding, both sides of the nose can be packed to provide some counter pressure to the nasal septum.
  - Seek senior input if you are inexperienced, or not confident with bilateral packing, as nasal septal perforation may occur.[10]

If anterior non-dissolvable nasal packing does not control the bleeding, seek senior advice on further management.

Practical tip

Follow the points below to ensure optimal use of anterior nasal packs.

Place all anterior packs as horizontally as possible to avoid misplacement.
Rapid Rhino^® and Merocel^® packs are equally effective, but Rapid Rhino^® may be less painful to insert and easier to remove than Merocel^®.[6][40][41]
Traditional ribbon gauze soaked in bismuth iodoform paraffin paste (BIPP) is as effective as nasal tampons, but is more difficult to insert.

Observe the patient for at least 30 minutes to check there is no bleeding from the nose or into the pharynx.

Re-examine the oropharynx after inserting the nasal pack as blood may divert posteriorly or you may have missed a posterior source for the epistaxis.

Do not prescribe routine systemic antibiotics after insertion of anterior nasal packs unless they are in place for longer than 48 hours.[6]

Pack removal

Non-dissolvable nasal packs should be removed within 24 hours of insertion if there is no evidence of active bleeding (with leeway for daylight hours).[6]

The nose should then be re-examined and an assessment made as to the need for cautery.[6][26]
If necessary, rigid endoscopy should be performed to identify and cauterise the bleeding point if this is not evident from anterior rhinoscopy.[6]

Practical tip

When removing a nasal pack:

Apply a mixture of topical vasoconstrictor, such as oxymetazoline, and lidocaine (according to local protocols) to the sponge pack
- The vasoconstrictor shrinks adjacent mucosa
- The lidocaine provides analgesia
Saturate the pack to promote softening and lubrication to discourage mucosal trauma and re-bleeding.

Plus – analgesia

Back

Plus –

analgesia

Treatment recommended for ALL patients in selected patient group

Prescribe adequate analgesia according to your local pain score or pain ladder protocol.

Paracetamol is usually appropriate.
DO NOT prescribe a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen to a patient on anticoagulation or to older people.
- In practice, you can prescribe a single dose of an NSAID for most other patient groups with epistaxis.
Opioid analgesics may be necessary in some patients.
- Use opioid analgesics with caution in older and shocked patients.

Avoid medications containing aspirin.

Primary options

paracetamol: children: consult specialist for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

Tertiary options

codeine phosphate: children: consult specialist for guidance on dose; adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day

morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Plus – supportive care ± admission

Back

Plus –

supportive care ± admission

Treatment recommended for ALL patients in selected patient group

In addition to stopping the bleeding, monitor vital signs, supplement oxygen, obtain intravenous access, maintain the airway, and support breathing and circulation if required.

For more information on resuscitation, see Shock.

Allocate patients with epistaxis to an area of the emergency department where they can be observed closely, as dislodgement of blood clot may sometimes lead to catastrophic bleeding.[6]

Establish intravenous access

Establish intravenous access with a large-bore cannula at the same time as taking bloods, if indicated, in:

Older patients
Patients on anticoagulants
Haemodynamic compromise
Profuse bleeding
Bleeding >20 minutes.

Control raised blood pressure

The relationship between epistaxis and hypertension is complex and remains unclear.[10] There is a paucity of evidence and guidance on how and when to treat hypertension in patients with epistaxis.

In practice, if the patient is hypertensive, consider treatment according to hypertension guidelines and discuss a treatment plan with a senior colleague. See Assessment of hypertension.

Practical tip

Monitor blood pressure in patients with acute nosebleeds, and base decisions about blood pressure control on:[10]

The severity of the patient's nosebleed
The inability to control the bleeding
Individual patient comorbidities
The potential risks of blood pressure reduction.

If hypertension persists after severe epistaxis, request cardiovascular evaluation to screen for underlying hypertensive disease.[31]

Consider admission

Consider whether your patient needs admission. Most patients with epistaxis controlled by cautery or anterior tampon packing do not need hospital admission.[42]

Some patients requiring non-dissolvable packing because of ineffective earlier measures or profuse bleeding may need admission.[26] Consult your local protocol.
Admission and further observation may be needed in patients with anterior packs in place and:[43]
- Shock
- Haemodynamic instability
- Haemoglobin <10 g/dL
- Anticoagulant medication
- Recurrent epistaxis following a previous episode requiring nasal packing within the last 7 days
- Uncontrolled hypertension
- Significant comorbid illness
- Difficult social circumstances
- Suspected posterior bleed (bleeding is profuse, from both nostrils, and the bleeding site cannot be identified on examination).

In UK practice, all children with nasal packs are admitted for observation because of the risk of airway compromise.
- Admit for 48 hours and remove the nasal pack prior to discharge.

If the patient presents in primary care, arrange for transfer to secondary care if any of the following factors exist:[29]

Epistaxis continues after anterior packing (if the facilities and expertise are available for anterior packing)
A nasal pack is in place (even if bleeding has stopped)
The patient is on anticoagulant therapy (as a clotting screen will be needed)
The cause provokes concern (e.g., leukaemia/tumour)
An underlying cause is likely (e.g., conditions predisposing to bleeding, such as haemophilia or leukaemia)
Significant comorbidity (e.g., coronary artery disease, severe hypertension, severe anaemia)
Child aged <2 years
Frailty or old age.

Consider – treatment of underlying cause

3rd line – referral to ENT specialist for posterior packing

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3rd line –

referral to ENT specialist for posterior packing

If epistaxis continues after unilateral or bilateral anterior nasal packing, the bleeding is most likely to be coming from the posterior nasal cavity.

Refer patients with posterior epistaxis to the ENT department for posterior packing, endoscopy with cauterisation, or ligation of the sphenopalatine artery.[6]

Practical tip

If the patient is becoming haemodynamically unstable and there is likely to be a delay before ENT consultation, use two Foley catheters to temporarily control blood loss in the emergency department. Seek senior assistance if you are not experienced in this procedure.

Insert size 12 catheters one at a time through the nostril, along the floor of the nose, and into the nasopharynx until you can see them in the pharynx.

Inflate each balloon with 5 to 10 mL of water and then apply gentle traction to compress the bleeding vessels in the posterior nasal cavity.

Combined non-dissolvable anterior and posterior nasal packs should be considered.[6]

Uncertainty exists about the need for routine antibiotic cover for posterior packs.[6] Consult your local protocol.

A variety of posterior packing options exist. UK ENT departments commonly use:

A double balloon epistaxis device, or
A traditional gauze anterior pack with a posterior size 12 French urinary catheter.

Surgery and interventional radiology are effective in managing epistaxis that has not responded to first aid and nasal packing, or if bleeding recurs when adequate packing is removed.[6] Options include:[26]

Endoscopic examination of the nose with or without cautery, as appropriate
Sphenopalatine artery ligation
Anterior ethmoid artery ligation (if traumatic)
Embolisation.

Plus – analgesia

Back

Plus –

analgesia

Treatment recommended for ALL patients in selected patient group

An intravenous opioid analgesic is usually required before posterior packing because it can be very painful or uncomfortable.

Use opioid analgesics with caution in older and shocked patients.

After the procedure, prescribe adequate analgesia according to your local pain score or pain ladder protocol.

Paracetamol may be appropriate.
DO NOT prescribe a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen to a patient on anticoagulation or to older people.
- In practice, you can prescribe a single dose of an NSAID for most other patient groups with epistaxis.
Opioid analgesics may be necessary in some patients.

Avoid medications containing aspirin.

Primary options

paracetamol: children: consult specialist for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

Tertiary options

codeine phosphate: children: consult specialist for guidance on dose; adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day

Consider – anti-emetic

Plus – supportive care + admission

Back

Plus –

supportive care + admission

Treatment recommended for ALL patients in selected patient group

In addition to stopping the bleeding, monitor vital signs, supplement oxygen, obtain intravenous access, maintain the airway, and support breathing and circulation if required.

For more information on resuscitation, see Shock.

Allocate patients with epistaxis to an area of the emergency department where they can be observed closely, as dislodgement of blood clot may sometimes lead to catastrophic bleeding.[6]

Establish intravenous access

Establish intravenous access with a large-bore cannula at the same time as taking bloods, if indicated, in:

Older patients
Patients on anticoagulants
Haemodynamic compromise
Profuse bleeding
Bleeding >20 minutes.

Control raised blood pressure

The relationship between epistaxis and hypertension is complex and remains unclear.[10] There is a paucity of evidence and guidance on how and when to treat hypertension in patients with epistaxis.

In practice, if the patient is hypertensive, consider treatment according to hypertension guidelines and discuss a treatment plan with a senior colleague. See Assessment of hypertension.

Practical tip

Monitor blood pressure in patients with acute nosebleeds, and base decisions about blood pressure control on:[10]

The severity of the patient's nosebleed
The inability to control the bleeding
Individual patient comorbidities
The potential risks of blood pressure reduction.

If hypertension persists after severe epistaxis, request cardiovascular evaluation to screen for underlying hypertensive disease.[31]

Hospital admission

Patients requiring a posterior pack should be admitted.[26]

Because of risk of hypoxia, some hospitals require intensive care unit (ICU) observation of patients with posterior packing; others consider this appropriate specifically for older people and patients with comorbidities.

Follow local post-packing observation protocols.

Patients requiring nasendoscopy or surgery usually require admission, depending on the procedure.

Consider – treatment of underlying cause

ONGOING

epistaxis resolved

1st line – topical intranasal antibiotic or petroleum jelly

Plus – nasal hygiene education

Consider – follow-up

Back

Consider –

follow-up

Additional treatment recommended for SOME patients in selected patient group

Following pack removal or cautery, discharge clinically stable patients after 4 hours.[6]

No follow-up is necessary for patients whose epistaxis has:

Stopped spontaneously
Been controlled by first aid measures
Responded to cautery.

Arrange an ENT follow-up appointment for patients discharged with an anterior nasal pack. The ENT department should remove the pack within 24 hours (with leeway for daylight hours) and can assess whether cautery is necessary.[26]

Refer patients with an underlying condition predisposing to epistaxis (including primary bleeding disorders, haematological malignancies, intranasal tumours, or vascular malformations) for appropriate follow-up.[10]

Consider referring patients with recurrent epistaxis to the ENT clinic for further assessment and management.[26]
Consultation may be necessary with haematology and appropriate specialities if the patient requires long-term anticoagulant therapy and epistaxis is difficult to control.[6]

Practical tip

Do not prescribe routine antibiotic cover for patients with an anterior nasal pack that will only be in place for up to 48 hours.[6][16]

recurrent epistaxis

1st line – referral to ENT specialist

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Epistaxis

Treatment algorithm

active epistaxis: major haemorrhage

follow local major haemorrhage protocol

Practical tip

resuscitation and supportive care ± admission

nasal first aid

Practical tip

tranexamic acid

Practical tip

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

active epistaxis: no major haemorrhage

nasal first aid

Children

Practical tip

vasoconstrictor ± local anaesthetic nasal spray

Practical tip

Practical tip

Practical tip

Children

supportive care ± admission

Establish intravenous access

Control raised blood pressure

Practical tip

Children

Consider admission

safeguarding (in children)

persistent epistaxis despite initial measures

electrocautery or chemical cautery

Practical tip

Practical tip

Practical tip

Children

vasoconstrictor ± local anaesthetic nasal spray

supportive care ± admission

Establish intravenous access

Control raised blood pressure

Practical tip

Consider admission

treatment of underlying cause

anterior nasal packing

Practical tip

Non-dissolvable nasal packing

Practical tip

Pack removal

Practical tip

analgesia

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

Tertiary options

supportive care ± admission

Establish intravenous access

Control raised blood pressure

Practical tip

Consider admission

treatment of underlying cause

referral to ENT specialist for posterior packing

Practical tip

analgesia

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options