Epistaxis (Nosebleeds)
NICE CKS Epistaxis. Last revised Oct 2024.
Background
Classification
Epistaxis can be classified into 2 main groups:
| Classification | Implicated vessel | Description |
|---|---|---|
| Anterior epistaxis | Kiesselbach plexus (Little's area of the anterior nasal septum) | 80-95% cases |
| Posterior epistaxis | Branches of the sphenopalatine artery in the posterior nasal cavity | Usually in older people |
Causes
Local causes of damage to blood vessels:
- Trauma (e.g. nose picking, nasal fractures, septal perforation)
- Nasal oxygen therapy
- Inflammation (e.g. chronic sinusitis, nasal polyps, allergic rhinosinusitis)
- Topical drugs (e.g. cocaine, decongestants, corticosteroids)
- Vascular causes (e.g. HHT, GPA)
- Post-operative bleeding
- Tumours (e.g. angiofibroma, squamous cell carcinoma)
General causes of vessel damage (non-specific):
- Atherosclerosis
- Clotting disorder (e.g. vWD, haemophilia, leukaemia, thrombocytopaenia)
- Anti-thrombotic drugs (antiplatelet and anticoagulants)
- Excessive alcohol consumption
- Environmental factors (temperature, humidity, altitude, exposure to irritants)
Guidelines
Investigation and Diagnosis
Clinical diagnosis. Laboratory investigations are not usually required unless an underlying cause is suspected.
- Examine both nasal passages
- Ideally with a nasal speculum and adequate lighting
Features suggestive of a posterior bleed:
- Bleeding is profuse
- Bleeding from both nostrils
- Bleeding site cannot be identified on speculum examination
- Bleeding first started down the throat
Management
Acute Epistaxis
Haemodynamically Unstable
- Immediate transfer to A&E
- Consider tranexamic acid 1g PO while awaiting hospital transfer to major haemorrhage
Stable
If posterior epistaxis is suspected → admit to hospital immediately
Otherwise, manage as following:
| Steps | Management | Description |
|---|---|---|
| Step 1 | First aid measures |
|
| Step 2 (if bleeding did not stop after 10-15 mins of first aid) | Nasal cautery or nasal packing |
If nasal cautery and nasal packing are not available in primary care → admit to hospital |
| Step 3 (if the above failed) | Secondary care management | Options include:
|
Complications of Treatment
Potential complications of nasal cautery:
- Septal perforation
- Therefore avoid performing on both sides of the septum
Potential complications of nasal packing:
- Sinusitis
- Septal haematoma / abscess
- Pressure necrosis
- Toxic shock syndrome
Management After Resolution
If the bleeding stops with first aid measures:
- Consider Naseptin® (chlorhexidine and neomycin) cream – QDS for 10 days
- If allergic to neomycin / peanus / soya → consider mupirocin nasal ointment
If the bleeding stops with nasal cautery:
- Dab the cauterised area with a clean cotton bud
- Apply Naseptin® (chlorhexidine and neomycin) cream – QDS for 10 days
- Observe the patient for 15 min to ensure bleeding is controlled
- Advise the person to avoid blowing their nose for a few hours
After nasal packing:
- Admit for observation
Recurrent Epistaxis
Advise the person on first aid measures to control bleeding during an acute episode
Determine if there is an underlying cause for epistaxis:
- Consider FBC
- If < 2 y/o → consider referral to a paediatrician as an underlying cause is likely
If there is unlikely an underlying cause of the epistaxis:
- 1st line: topical Naseptin® (chlorhexidine and neomycin) cream QDS for 10 days
- If allergic to neomycin / peanus / soya → consider mupirocin nasal ointment
- 2nd line: nasal cautery