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 of bleeding disorder.
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 or recurrent episodes check FBC
- If on anticoagulants or suspect coagulopathy check clotting, renal and liver function.
Sinonasal neoplasm is very rare but can present with unilateral persistent epistaxis. Red flags to be aware of include facial pain/swelling, otalgia, unilateral nasal obstruction, reduced sense of smell, visual and dental symptoms – see Rhinosinusitis (Adult) – RefHelp.
C.M – 4-9-26
Adult ENT services are sited in Lauriston Buildings and St John’s Hospital.
Who to refer:
Emergency referral to A&E:
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 who will refer to ENT if necessary.
ENT referral:
- Recurrent epistaxis not improved with primary care management refer to adult service 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 Outpatients.
- If epistaxis is unilateral and associated with lesion visualised in anterior nose or significant pain/obstruction refer as urgent for review in Outpatients.
First aid advice for patients – Nosebleed | NHS inform:
- Sit patient down
- Lean patient forward
- Pinch the lower part of the nose between the thumb and forefinger
- Pinch nose for 10 minutes
- Do not release the pressure.
Primary care options:
- Neomycin / chlorhexidine ointment 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; only undertake if the bleeding site is visible in Little’s area; stage cautery one side and then the other 4-6 weeks later)
- If epistaxis recurs on stopping topical antibiotic ointments, try petroleum jelly prn.
