Assessment
- Duration, predisposing factors, history of injury
- Determine whether bleeding is unilateral or bilateral
- Determine whether bleeding is anterior or posterior
- Medications – NSAIDS, aspirin, Warfarin or DOACs
- Past medical history – coagulopathy, platelet disorder or hypertension. If suspecting blood dyscrasia
- Thorough history (including bruising, bleeding)
- Family history
Examination
- BP, pulse if active bleeding
- Anterior rhinoscopy – ?bleeding point, visible vessels in Little’s area, crusting, septal perforation, mass present.
- Posterior epistaxis indicated by failure to visualise an anterior source, haemorrhage from both sides or oro-pharyngeal blood.
Investigation
- If significant blood loss, recurrent episodes check FBC
- If on anticoagulants or suspect coagulopathy check clotting, renal and liver function
Secondary Care Referral
Adults
- If recurrent epistaxis not improved with primary care management refer to adult service (SJH/LB) for routine review. Consider withholding any anticoagulants.
- If recurrent epistaxis resulting in significant drop in Hb or has history of haematological problem (low platelets/abnormal clotting) refer as urgent for review in OP
- If epistaxis is unilateral and associated with lesion visualised in anterior nose or significant pain/obstruction refer as urgent for review in OP (SJH/LB)
- If episode of epistaxis not controlled with first aid measures and still bleeding after 20 minutes compression, especially if cardiovascularly unstable transfer to A+E (RIE/SJH), who will refer to ENT if necessary.
First Aid Advice
- Pinch soft anterior part of nose for 20 minutes
- Lean forward
Primary care options
- Naseptin ointment (adults) twice daily for 2 weeks (NOT SUITABLE FOR PEANUT ALLERGY in which case Mupirocin is an option)
- Cautery using silver nitrate sticks if able to provide in community (avoid cautery bilaterally at same time, stage cautery one side and then the other 4-6 weeks later)
- If Epistaxis recurs on stopping Naseptin, try Vaseline prn
