Epistaxis 👃🩸
Clinical guide for managing epistaxis (nosebleed). Anterior and posterior epistaxis treatment, nasal packing, cautery, and emergency management for on-call doctors.
🧯 Safety & PPE
- Always don PPE: gloves, gown, goggles (“3 Gs”) before examining.
- Assess ABCs and ensure hemodynamic stability before nasal exam.
🧠 Definition
- Bleeding from nasal mucosa, often anterior (Kiesselbach’s plexus).
- May be spontaneous or trauma-related, often recurrent.
📞 Immediate Questions
- How much blood? Persistent or resolved?
- Side of bleed? Any clots or swallowing blood?
- Anticoagulants or antiplatelets? (Warfarin, DOACs, aspirin)
- Nose picking, trauma, recent nasal procedures?
- Hypertension history?
📋 Common Causes
- Local trauma (e.g. nose picking)
- Dry nasal mucosa
- HTN or anticoagulation
- Bleeding disorders
- Tumour (esp. if unilateral and recurrent)
🧾 History
- Onset, side, volume, duration
- Hx of bleeding diathesis or easy bruising
- Current medications (especially anticoagulants)
- Recent nasal surgery or oxygen use
🩺 Examination
- Ensure patient has blown their nose gently to clear clots.
- Check vitals – especially HR, BP, oxygenation.
- Use a head torch or nasal speculum to inspect anterior septum (Kiesselbach’s plexus).
- Look for clots, active bleeding, or deviation.
- Posterior pharynx – check for dripping blood.
- Note signs of coagulopathy (e.g. bruises, petechiae).
🔍 Investigations
- FBC, U&E, coagulation profile only if bleeding is ongoing or patient is unstable.
- Check INR if on warfarin.
- Consider ECG in elderly if significant blood loss.
💊 Initial Management
- Sit patient forward and pinch soft part of nose for 10–15 minutes.
- Apply cold compress or ice pack to bridge of nose.
- Use a nose clip or tongue depressors taped together if available.
- Administer topical vasoconstrictor (e.g. adrenaline 1:10,000) with tranexamic acid if protocol allows.
- Consider lidocaine with vasoconstrictor via atomizer for visualization.
- If a bleeding point is visible: cauterize with silver nitrate (only one side).
- If not controlled: insert nasal tampon (e.g. RapidRhino, Merocel, Nasopore) and inflate per protocol.
⚠️ Escalation
- ENT referral if posterior bleed suspected or uncontrolled bleeding.
- Admit if on anticoagulants, hypertensive crisis, or ongoing/recurrent bleeding.
- Start antibiotics if packing used.
- Correct any coagulopathy (e.g. vitamin K, FFP, platelet transfusion).
- Reassess post-intervention; monitor vitals and observe for rebleed.
📦 Discharge & Follow-Up
- If packed: anterior balloon may be deflated after 6 hours, posterior after 48+ hours.
- Avoid nose blowing, strenuous activity, or hot drinks post-discharge.
- Use nasal lubricants, saline sprays, and keep mucosa moist.
- Follow-up with ENT if recurrent or unexplained bleeding.
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:03 ATRP re: epistaxis Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [esp. anticoagulation, hypertension, nasal pathology] 🧾 Hx: • Onset, side, severity (trickle vs profuse) • Duration and frequency • Precipitating trauma or spontaneous • Anticoagulants or antiplatelets? • Previous episodes or nasal issues? 🩺 Exam: • Vitals: HR __ BP __ RR __ SpO₂ __ Temp __ • Active bleeding? Side? Visible source? • Nasal trauma, foreign body, mucosal dryness • Look for posterior bleed (throat) 📋 Impression: Likely [anterior / posterior] epistaxis 📌 Plan: • Sit up, pinch soft part of nose x10–15 min • Consider topical vasoconstrictor (e.g. co-phenylcaine) • Cautery if visible anterior vessel • Pack if ongoing bleeding • Monitor obs ± bloods (FBC, coag) • Escalate ENT if persistent or posterior 👤 [Your Name], [Role] IMC: _______
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