EMed

Epistaxis

Assessment

Points to note on the history:

  • Any history of trauma
  • Timing of onset, duration and side of bleed
  • Is it continuing to bleed
  • Blood swallowed, or sensation of blood in the pharynx?
  • Previous episodes
  • PMHx e.g. previous nasal surgery, hypertension, sinusitis
  • Recent URTI/rhinitis, TB, sarcoid, Wegeners', nose picking, septal defects
  • Drug history e.g. anti-hypertensives, steroid nose drops/sprays, aspirin / warfarin or DOAC that may require reversing

Points to note on examination

  • Any airway compromise?
  • Pulse, BP, capillary refill
  • Side of bleed
  • Presence of obvious bleeding point in Little's area
  • Blood in oropharynx/ blood being coughed up or fresh haematemesis
  • Epistaxis can be life threatening
  • Rapid primary survey then more detailed history and examination
  • Patients should be and be reassessed regularly

Examination

To examine the nose, if there is clot blocking your view, ask the patient to gently blow the nose, one nostril at a time to clear it. Then, gently, elevate the tip of the nose with one finger, whilst shining a torch into the nasal antrum. This should allow a view of Little's area. Thudicums may be used, and are available in nasal packing packs, or ENT emergency packs.

Any septal deviation should be noted, as well as bony deformity on external inspection (especially in the case of traumatic epistaxis).

The oropharynx should be visualised with a tongue depressor and torch.

General advice

  • Suit up! "3 Gs": gloves, gown, and goggles
  • Resuscitate your patient first if necessary
  • Quick but comprehensive history (left)
  • The patient should be sitting up and bending slightly forwards to prevent blood from tracking into the pharynx

Management

  • * Use either swimmers' nose clip or 4 tongue depressors taped together in the middle to act as a wooden 'nose peg'
  • ** To gauze, add:
    1. Adrenaline 0.5 mg (5 mL of 1:10,000)
    2. TXA 1 mg of IV liquid preparation
  • *** A mixed adrenaline/lidocaine vial applied with a MAD device on a 3mL syringe is effective if co-phenylcaine (which is expensive) is not available
  • **** Nasopore is expansile, providing haemostasis via prothrombotic and tamponading effects. It resorbs within 5-7 days
  • Posterior application requires nasal forceps
  • † Not evidence-based, but is standard local approach

Content by Dr Finn Coulter, Dr Mohsin Tahir, Dr ÍOS. Last review Dr ÍOS 25/05/25.