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
- Perform 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 minutes 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 comorbidities); reversal of anticoagulation 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 1 ml 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 ooze 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 measures may include: bilateral anterior packs, removal of anterior pack and insertion of posterior pack (or Foley catheter), rigid nasendoscopy and direct cautery, surgical management
Flowchart
Page last reviewed: 30 July 2026