Epistaxis

Triage questions


Question 1: Has the bleeding stopped?

Yes:

  • Take a history: determine laterality and volume, preceding trauma, predisposing factors, any recurrence and/or previous treatment or admissions, any red flag features?

  • Peform an ENT examination including anterior rhinoscopy (look specifically at Little’s area)

  • Offer topical Naseptin TDS or QDS for 10 to 14 days (unless peanut allergy) then discharge home with safety net advice


No: Go to Question 3.


Question 2: Does this patient need to be seen in ENT casualty clinic?

  • Consider referral to ENT casualty or rapid access clinic and/or semi-elective discussion with ENT registrar if epistaxis is recurrent or complex, or patient is very frail, or there have been multiple emergency presentations despite Naseptin cream; also beware of any red flag symptoms and signs


Question 3: Has adequate first aid been given?

No:

  • Apply firm and constant pressure for a minimum of 15 to 20 mins to the anterior nares (Hippocratic or Trotter’s method)

  • Adjuncts to first aid include applying an ice pack to the nape of neck or forehead, and tranexamic acid (if no significant co-morbidities); reversal of anti-coagulation should be considered in unremitting bleeding but not before adequate first aid has been attempted

  • Ensure adequate IV access and resuscitation, if appropriate


Yes: Go to Question 4.


Question 4: Has bleeding persisted despite adequate first aid?

Yes (small volume bleeding or oozing without signs of hypovolaemic shock): consider direct and vasoconstrictor therapy

  • Gentle, directed suction only to identify potential bleeding point(s)

  • Direct application of 0.5 to 1ml co-phenylcaine or 1:10,000 adrenaline on ribbon gauze or similar, while applying pressure

  • Consider judicious nasal cautery or application of Floseal haemostatic matrix (if trained)

Yes (heavier bleeding with minimal response to pressure, or (rarely) haemodynamically unstable): consider anterior nasal packing


Question 5: Has anterior packing stopped the bleeding?

Yes: it is normal for a small amount of ozze to continue for a short period, and for the pack to be a little wet; old clots might also pass into the oropharynx

  • Monitor the patient and consider overnight admission or a 6 to 24 hour interval before removal of packing

  • Some units may allow discharge home with a pack in situ, if patient has reliable supervision and transport; removal of packing can be undertaken in the casualty/rapid access clinic


No: Ongoing heavy bleeding anteriorly or posteriorly into oropharynx, or through the other nostril

  • Ensure the anterior pack is correctly inserted: it should not be hanging out of nares or into oropharynx and should be inflated to an adequate pressure (check pilot balloon)

  • If the pack has been inserted correctly, discuss with the ENT Registrar

  • Further measure may include: bilateral anterior packs, removal of anterior pack and insertion of posterior pack (or Foley catheter), rigid nasendoscopy and direct cautery, surgical management




Page last reviewed: 6 March 2024