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