Epistaxis Algorithm

Safety

Red Flags — Massive haemorrhage, blood dyscrasias, malignancy

Done

Urgent exclusion of life-threatening bleeding and serious underlying pathology. Primary care covers first aid, assessment, selective cautery and referral; nasal packing, topical vasoconstrictor pledgets, posterior bleeds and anticoagulant reversal belong in ENT/emergency settings.

Massive ongoing bleeding Profuse blood loss, haemodynamic compromise (hypotension, tachycardia), pallor, dizziness, airway compromise or aspiration risk, major trauma or suspected skull-base/facial fracture → 999 or immediate A&E (posterior bleed, arterial source)

Persistent despite correct pressure If bleeding continues after 10–15 minutes of uninterrupted, correctly applied pressure, reassess urgently. If it remains active after a further period of pressure and appropriate local measures → Same-day ENT or emergency assessment. Do not keep a patient with ongoing significant bleeding in a routine primary-care pathway. Transfer earlier if haemodynamic compromise, anticoagulated with significant ongoing bleeding, blood in the airway/pharynx, suspected posterior bleed, inability to assess or treat safely, or major comorbidity/frailty.

Recurrent bilateral bleeds Both nostrils bleeding simultaneously or alternating frequently → Urgent ENT (hereditary haemorrhagic telangiectasia, systemic cause)

Easy bruising / petechiae Spontaneous bruising, petechial rash, bleeding gums, menorrhagia → Very urgent bloods (48 h) FBC and clotting — consider in adults, offer in children (NICE NG12) (thrombocytopenia, leukaemia, coagulopathy). Child with unexplained petechiae → Immediate specialist assessment (NICE NG12)

Anticoagulation + uncontrolled bleed Warfarin/DOAC/aspirin with epistaxis not stopping → Same-day assessment; check INR if on warfarin (INR does not assess DOACs); major or uncontrolled bleeding → emergency hospital management and specialist reversal protocol

Unilateral + nasal obstruction Persistent unilateral nasal obstruction, blood-stained discharge, recurrent unilateral epistaxis, facial pain/swelling, anosmia, cranial-nerve signs or a visible nasal mass. Do not biopsy or repeatedly cauterise an unexplained unilateral mass in primary care → Urgent referral (local pathway) ENT referral (nasal tumour, sinonasal malignancy; local head and neck pathway)

Adolescent male, unilateral obstruction + profuse epistaxis Consider juvenile nasopharyngeal angiofibroma → Urgent specialist imaging/ENT assessment; avoid nasal biopsy

Child <2 years with epistaxis Uncommon age for nosebleeds — consider a bleeding disorder or non-accidental injury → Same-day paediatric assessment; follow local safeguarding procedures (also foreign body; tumour rare)

Suspected posterior or severe bleed Persistent bleeding despite correctly applied pressure and anterior measures, blood entering the pharynx, bleeding from both nostrils, no visible anterior bleeding point, or significant haemodynamic compromise (none is diagnostic alone) → A&E (urgent hospital/ENT assessment)

Posterior epistaxis is a medical emergency — bleeding from sphenopalatine or ethmoidal arteries, difficult to control with simple pressure. Blood flows down throat (patient swallows/vomits blood). Requires ENT packing or interventional radiology (arterial embolisation). Can cause airway obstruction or aspiration. Posterior bleeding is difficult to confirm in primary care and requires urgent hospital/ENT assessment.

Massive haemorrhage causes hypovolaemic shock. Elderly patients on anticoagulants are highest risk. Requires IV access, resuscitation, transfusion, urgent ENT/interventional radiology. Death from epistaxis is rare but occurs, mostly in elderly anticoagulated patients.

Unilateral bleeds with obstruction require urgent ENT assessment to exclude nasal malignancy. Do not biopsy or repeatedly cauterise an unexplained unilateral mass in primary care. Squamous cell carcinoma, adenoid cystic carcinoma, melanoma all present with unilateral bleeding + obstruction. Delay = advanced disease, poor prognosis. Urgent suspected head and neck cancer referral (local pathway) is mandatory.

Diagnose

History — Frequency, severity, triggers, medications

Done

Take detailed history focusing on bleeding pattern, volume, triggers, and underlying risk factors.

Bleeding characteristics

Frequency: First episode vs recurrent (daily, weekly, monthly). Laterality: One nostril vs both/alternating — suggestive only: an anterior bleed can drain posteriorly and heavy anterior bleeding may appear bilateral. Duration: Seconds vs minutes vs hours. Volume: Drops vs tablespoons vs cups (quantify).

First aid attempted

Correct technique: Sit forward, pinch soft part of nose (not bridge), 10-15 minutes continuous pressure. Incorrect: Lying back (swallows blood, nauseates), ice pack instead of pressure (comfort only — not a substitute), head between knees. Ask what patient did — incorrect technique = not truly refractory bleed.

Triggers

Local: Nose picking, trauma, nose blowing, dry air (winter heating, air conditioning), intranasal drugs (cocaine, steroid sprays). Systemic: Straining, coughing, hot showers, alcohol. Iatrogenic: Recent nasal surgery, cautery, packing removal.

Medications

Anticoagulants: Warfarin, DOACs (apixaban, rivaroxaban, edoxaban, dabigatran), aspirin, clopidogrel — record the indication and, for DOACs, the time of the last dose and renal function. NSAIDs: Ibuprofen, naproxen (impair platelet function). Nasal sprays: Steroid sprays (thinning septum), decongestants (rebound vasodilation). Herbal: Ginkgo, ginseng, fish oils (antiplatelet).

Bleeding elsewhere

Easy bruising, bleeding gums, heavy periods, PR bleeding, haematuria, haemoptysis. Presence = systemic bleeding disorder (coagulopathy, thrombocytopenia, platelet dysfunction). Absence = local nasal cause.

PMH

Hypertension (may be a risk factor, a consequence of distress or unrelated), liver disease (coagulopathy), renal failure (platelet dysfunction, uraemia), hereditary haemorrhagic telangiectasia (HHT — family history of nosebleeds + telangiectasia).

Age pattern

Children (2-10 years): Common, anterior, self-limiting (Little's area trauma). Young adults: Rare unless trauma, cocaine. Elderly (>60 years): Posterior bleeds, anticoagulation, hypertension. Bimodal distribution.

Correct first aid technique is critical — most anterior nosebleeds stop with proper pressure (pinch soft part 10-15 minutes). Many "refractory" bleeds are actually inadequate pressure (pinching bony bridge, insufficient duration, looking up to check bleeding = releasing pressure). Education on technique prevents ED attendances.

Anticoagulation increases bleeding risk but is rarely the sole cause of epistaxis. Nosebleed in an anticoagulated patient = identify bleeding site (usually Little's area), control the bleed, check INR if on warfarin and discuss abnormal results with the anticoagulation service, but do not routinely stop anticoagulation for minor controlled bleeding.

Bilateral bleeding may suggest a systemic cause — coagulopathy, thrombocytopenia, or posterior source — but is not diagnostic: heavy anterior bleeding can appear bilateral. Unilateral bleeding suggests local pathology (Little's area trauma, tumour, vascular malformation). Laterality directs investigation.

Diagnose

Classification — Anterior vs Posterior, primary vs secondary

Done

Classify based on anatomical site and underlying cause. Determines management urgency.

Anterior epistaxis

Site: Little's area (Kiesselbach's plexus) — anterior inferior septum where 5 arteries anastomose. Features: Unilateral, visible bleeding from one nostril, stops with pressure. Cause: Trauma (nose picking, dry air, nose blowing). Benign, self-limiting

Posterior epistaxis

Site: Sphenopalatine artery, ethmoidal arteries (posterior nasal cavity). Suspect when: persistent bleeding despite correctly applied pressure and anterior measures, blood entering the pharynx, bleeding from both nostrils, no visible anterior bleeding point, or significant haemodynamic compromise — none is diagnostic alone. Difficult to confirm in primary care; requires urgent hospital/ENT assessment. Risk: Elderly, hypertensive, anticoagulated. Medical emergency

Primary (idiopathic)

No underlying cause identified. Local vascular fragility at Little's area. Management: Conservative (pressure, cautery if recurrent). Prognosis: Excellent, self-limiting, outgrown in children by adolescence.

Secondary epistaxis

Underlying systemic cause: Anticoagulation, hypertension, bleeding disorder, liver disease, malignancy. Investigation: Selective FBC/clotting as clinically indicated, pulse/BP, examination. Management: Treat underlying cause + local measures.

HHT (Osler-Weber-Rendu)

Hereditary Haemorrhagic Telangiectasia. Autosomal dominant. Features: Recurrent epistaxis from childhood, telangiectasia (lips, tongue, fingers), AVM (pulmonary, cerebral, hepatic). Diagnosis: Curaçao criteria — 3 or more = clinical diagnosis; 2 = possible HHT. Management: Refer to an HHT specialist centre (AVM screening, laser, bevacizumab); may need coordinated ENT, respiratory, hepatology, neurology and genetics input.

Trauma-related

Iatrogenic: Nasal surgery, septoplasty, cautery. External: Facial fracture, assault, RTA. Chemical: Cocaine (septal perforation), intranasal steroids (chronic use). Mechanical: NG tube, nasal CPAP.

Anterior vs posterior distinction is critical — determines management site (home vs hospital). Anterior bleeds managed in primary care with pressure ± cautery. Posterior bleeds require ENT packing or interventional radiology in hospital. Missing posterior bleed = massive haemorrhage, aspiration, death.

Primary epistaxis is diagnosis of exclusion — only diagnosed after excluding systemic causes (anticoagulation, blood dyscrasia, hypertension, malignancy). Young healthy patient with unilateral bleeding = likely primary. Elderly patient on warfarin with bilateral bleeding = secondary until proven otherwise.

HHT is underdiagnosed. Think of HHT in anyone with recurrent epistaxis starting in childhood. Curaçao criteria: epistaxis, telangiectasia, visceral AVMs, family history — 3 or more = clinical diagnosis; 2 = possible HHT. Diagnosis important because pulmonary AVMs cause stroke risk (paradoxical embolism) — treatable with coil embolisation.

Diagnose

Examination — Inspect nose, check BP, look for bleeding disorder

Done

Examine during or immediately after bleeding if possible. Focus on identifying bleeding site and systemic signs.

Vital signs

Pulse (tachycardia if significant blood loss), blood pressure and general haemodynamic status — repeat BP after haemostasis if elevated; do not assume hypertension caused the bleed, temperature (rarely elevated unless sinusitis/infection). Postural BP if suspecting volume depletion (elderly, prolonged bleeding).

Nasal inspection

External: Trauma, deformity, swelling, erythema. Anterior rhinoscopy: Use Thudichum speculum + headlight (or smartphone torch). Inspect Little's area (anterior septum) for visible vessel, clot, perforation. Blood clot removal: Gently blow nose to clear clot and identify bleeding point.

Bleeding site

Visible anterior source: Little's area (most common) — prominent vessel, fresh blood, unilateral. Posterior: Blood in nasopharynx (examine oropharynx — blood trickling down posterior wall). No visible source: Stopped bleeding or posterior (refer ENT for nasoendoscopy).

Septal abnormalities

Septal perforation (cocaine, chronic steroid spray, granulomatosis with polyangiitis), deviation (predisposes to dryness on convex side), crusting (atrophic rhinitis, granulomatosis with polyangiitis), telangiectasia (HHT — also check lips, tongue).

Signs of bleeding disorder

Petechiae (thrombocytopenia), purpura, bruising (easy bruising, multiple sites), pallor (anaemia from chronic blood loss), jaundice (liver disease coagulopathy), splenomegaly (portal hypertension, haematological malignancy).

HHT screening

Telangiectasia on: lips, oral mucosa, tongue, fingers, nail beds. Recurrent epistaxis plus telangiectasia and/or family history → refer to an HHT specialist centre (3 or more Curaçao criteria = clinical diagnosis; 2 = possible). Visceral AVM screening is arranged by the specialist centre. Check FBC and iron status if bleeding is recurrent.

Facial examination

Unilateral facial swelling, proptosis, cranial nerve palsies (sinonasal malignancy). Facial numbness (infraorbital nerve compression). Lymphadenopathy (cervical nodes — malignancy). Anosmia or a visible nasal mass → urgent ENT.

Identifying bleeding site enables targeted cautery — silver nitrate stick applied to a discrete visible vessel at Little's area is effective for recurrent anterior bleeds. Blind cautery without identifying site is ineffective and risks septal perforation. If site not visible, ENT nasoendoscopy needed.

Hypertension may be a risk factor, a consequence of distress or unrelated. Repeat BP after haemostasis if elevated. Severe hypertension should be managed according to the overall clinical picture; do not assume that hypertension caused the epistaxis or attempt rapid BP reduction solely because a nosebleed is occurring.

Septal perforation causes: cocaine (vasoconstriction → ischaemic necrosis), chronic intranasal steroid misuse (spray aimed at septum not turbinates), granulomatosis with polyangiitis (ANCA-associated vasculitis), trauma (repeated cautery). Large perforations whistle, crust, bleed recurrently.

Diagnose

Investigations — Selective testing if red flags or recurrent

Done

Investigate selectively: recurrent or severe bleeds, bleeding elsewhere, anticoagulated, red flags or suspected coagulopathy. A routine clotting screen is not useful in every patient with epistaxis.

FBC

Indications: Recurrent bleeds, easy bruising, petechiae, pallor, suspected anaemia from chronic blood loss. Check for: Hb (anaemia), platelets (thrombocytopenia — urgency depends on the count, active bleeding and clinical context), WCC (leukaemia). Check iron status in recurrent bleeding. Normal FBC does NOT exclude bleeding disorder (platelet function defects have normal count).

Clotting screen

Indications: Current anticoagulant treatment (INR for warfarin; INR does not assess DOAC effect), known liver disease, bleeding elsewhere, family history of bleeding, clinical suspicion of a coagulopathy, severe or recurrent bleeding, major bleeding requiring hospital treatment. Tests: PT/INR, APTT. Prolonged APTT = haemophilia, von Willebrand disease (refer haematology). Prolonged PT = warfarin, liver disease, vitamin K deficiency. A normal PT/APTT does not exclude von Willebrand disease or platelet-function disorders — refer to haematology if the history is suggestive, even if initial tests are normal.

Major bleeding (hospital)

FBC, U&E/creatinine, INR/PT, APTT and fibrinogen as clinically indicated, group and save/crossmatch; consider lactate and blood gas if shocked.

Blood pressure

Check pulse, blood pressure and general haemodynamic status. Repeat BP after haemostasis if elevated. Hypertension may be a risk factor, a consequence of distress or unrelated — manage according to the overall clinical picture, not by rapid reduction solely because a nosebleed is occurring.

Nasoendoscopy

Indications: Recurrent unilateral bleeds, no visible anterior source, suspected posterior bleed, unilateral obstruction, suspected malignancy. Performed by: ENT. Findings: Posterior bleeding point, tumour, polyp, AVM. NOT routine in simple anterior epistaxis.

CT/MRI sinuses

Indications: Suspected sinonasal malignancy (unilateral obstruction, facial swelling, cranial nerve signs), recurrent bleeds with negative nasoendoscopy. Arranged by: ENT. NOT primary care.

Do NOT investigate

Single anterior bleed in child/young adult with no red flags, normal examination, stopped with pressure. Benign self-limiting — reassure, teach first aid, Naseptin cream. Over-investigation causes anxiety.

FBC and clotting rarely find bleeding disorders in unselected epistaxis patients. Reserve for those with clinical features suggesting systemic cause (easy bruising, petechiae, bleeding gums, family history). Routine testing in healthy children with single nosebleed is low yield and unnecessary.

Anticoagulated patients — Warfarin: check INR when clinically indicated, particularly if bleeding is recurrent, prolonged or more than minor, and discuss abnormal results with the anticoagulation service. DOAC: INR does not assess anticoagulant effect — record the time of the last dose, renal function and indication. Major or life-threatening bleeding needs emergency hospital management and a specialist reversal protocol (NICE NG24: immediate prothrombin complex concentrate for emergency warfarin reversal in severe bleeding; current MHRA advice for DOAC reversal). GPs should not independently give vitamin K or PCC for epistaxis.

Nasoendoscopy is gold standard for visualising entire nasal cavity and nasopharynx. Identifies posterior bleeding points, tumours, AVMs not visible on anterior rhinoscopy. Flexible scope passed via nostril under local anaesthetic (co-phenylcaine spray). ENT procedure, not primary care.

Refer

Referral Criteria — When to escalate urgently

Done

Refer all posterior bleeds, uncontrolled anterior bleeds, and red flag features.

999 / A&E

Haemodynamic compromise or suspected major haemorrhage. Airway compromise or aspiration risk with ongoing bleeding. Suspected posterior bleed with persistent bleeding. Uncontrolled bleeding despite correct pressure and urgent local measures. Severe bleeding with significant anticoagulation. Major trauma or suspected skull-base/facial fracture.

Same-day ENT / A&E

Persistent bleeding after 10–15 minutes of correct pressure and reassessment · recurrent bleeding that is still active with no visible anterior source · suspected posterior bleeding · bleeding requiring packing · bleeding still active despite appropriate cautery · significant anaemia, thrombocytopenia or coagulopathy · anticoagulated patient with clinically significant ongoing bleeding · child under 2 years with epistaxis → same-day paediatric assessment (bleeding disorder, non-accidental injury; follow local safeguarding procedures)

Urgent ENT · suspected cancer

Persistent unilateral nasal obstruction, blood-stained discharge or recurrent unilateral epistaxis. Facial pain/swelling, anosmia, cranial-nerve signs or a visible nasal mass (local head and neck pathway). Adolescent male with unilateral obstruction + profuse epistaxis → consider juvenile nasopharyngeal angiofibroma (no biopsy; urgent imaging/ENT).

Urgent ENT

Recurrent bleeds despite cautery (bleeding now settled; still bleeding → same-day). No anterior source visible (needs nasoendoscopy; still bleeding → same-day). Suspected HHT (recurrent epistaxis + telangiectasia and/or family history → HHT specialist centre). Recurrent bleeding with normal ENT examination but ongoing concern. Septal perforation enlarging or symptomatic.

Haematology

Thrombocytopenia (urgency depends on count, active bleeding and context). Prolonged APTT (haemophilia, vWD). Suggestive bleeding history even with normal PT/APTT (vWD, platelet-function disorders). Easy bruising + bleeding elsewhere. Family history bleeding disorder. Recurrent epistaxis + normal ENT assessment (platelet function disorder).

Primary care

Simple anterior epistaxis controlled with pressure. Discrete visible Little's area source → cautery in practice if the clinician is trained and equipped. Recurrent but controllable → Naseptin (check peanut/soya allergy) or petroleum jelly/saline. Child with self-limiting bleeds → reassure, teach first aid.

Posterior epistaxis requires hospital admission — cannot be controlled with simple pressure. Requires ENT packing (anterior + posterior packs, or Foley catheter balloon tamponade), or interventional radiology (sphenopalatine artery embolisation). Delay = massive blood loss, aspiration, death.

Unilateral symptoms require urgent ENT assessment. Squamous cell carcinoma, adenocarcinoma, esthesioneuroblastoma all present with unilateral bleeding + obstruction. Urgent ENT referral (local head and neck pathway) for nasendoscopy + biopsy. Delay worsens outcomes.

Most anterior bleeds managed in primary care — most stop with pressure, and many recurrent bleeds settle with silver nitrate cautery when a bleeding point is visible. Only refer if: no visible source (needs nasoendoscopy), recurrent despite cautery (may need diathermy/laser), or red flags. Unnecessary ENT referrals burden limited capacity.

Treat

Acute Management — Pressure, packing, cautery

Done

Stop bleeding with first aid, then prevent recurrence with cautery or topical treatments.

Active bleeding (first aid)

Pressure technique First-line

Sit forward (not back). Pinch soft part of nose (not bony bridge) continuously 10-15 mins. Breathe through mouth. Spit blood, do NOT swallow. Do not release pressure to check. An ice pack may be used for comfort, but firm continuous pressure is the effective first-line intervention. If bleeding continues → reassess urgently; same-day ENT/A&E if it remains active.

Recurrent anterior bleeds

Silver nitrate cautery In-practice

Only when a discrete anterior bleeding point can be seen and the clinician is trained and equipped. Local anaesthetic (co-phenylcaine spray 5 mins). Silver nitrate stick applied to vessel 3-5 seconds. Avoid simultaneous cautery of both sides of the septum (perforation risk) — allow 4–6 weeks between sides. Often poorly tolerated by young children — do not force.

Unable to cauterise / no visible source

Nasal packing Secondary care

Should generally be performed in an appropriate ENT/A&E setting by trained staff (e.g. Merocel, Rapid Rhino). Posterior packing requires hospital admission and monitoring because of airway, hypoxia, aspiration and cardiovascular risks. Patients with packing require planned review and removal according to the pack used and local ENT protocol. Antibiotic prophylaxis is not automatic for every anterior nasal pack — follow the current local ENT protocol; antibiotics do not replace urgent ENT review for posterior packing or ongoing bleeding.

Step 1Pressure 10-15 minutes — First aid for all epistaxis. Stops most anterior bleeds. Pinch soft part (below bony bridge), sit forward, continuous pressure. Do NOT release to check bleeding before 10 minutes elapsed.

Step 2Topical vasoconstrictor (ENT/A&E only) — Topical vasoconstrictor/local anaesthetic pledgets may be used by appropriately trained clinicians in ENT or emergency settings according to local protocol. They are not routine primary-care treatment.

Step 3Silver nitrate cautery — Only when a discrete anterior bleeding point is visible and the clinician is trained and equipped. Local anaesthetic first (co-phenylcaine spray 5 mins). Apply stick to bleeding point 3-5 seconds. Warn: black eschar forms, falls off in 7-10 days. Avoid simultaneous cautery of both sides (allow 4–6 weeks between sides).

Step 4Nasal packing — If cautery fails or no visible source. ENT/A&E procedure by trained staff. Review and removal according to the pack used and local ENT protocol; antibiotic prophylaxis per local ENT protocol.

Step 5Interventional radiology — If packing fails. Sphenopalatine artery embolisation under fluoroscopy. Reserved for severe recurrent posterior bleeds. Complications: facial numbness, palatal necrosis (rare).

Cautery technique

Indications: Discrete visible anterior bleeding point, recurrent epistaxis from same site; trained and equipped clinician. Avoid: when the bleeding point cannot be visualised or bleeding is too profuse; simultaneous cautery of both sides of the septum (perforation risk — allow 4–6 weeks between sides). Often poorly tolerated by young children — do not force. Method: Co-phenylcaine spray 5 mins, silver nitrate stick to vessel 3-5 seconds, avoid excessive cautery.

Anticoagulation

Do not routinely stop prescribed anticoagulant or antiplatelet treatment for a minor, controlled epistaxis. Treat the bleeding locally and check the relevant medication history. Warfarin: check INR when clinically indicated, particularly if bleeding is recurrent, prolonged or more than minor; discuss abnormal results with the anticoagulation service. DOAC: do not use INR to assess anticoagulant effect; record the time of the last dose, renal function and indication; seek urgent haematology/acute medical advice for major or uncontrolled bleeding. Aspirin/clopidogrel: do not routinely stop secondary-prevention antiplatelet treatment; discuss with the prescribing specialist if bleeding is clinically significant. Major or life-threatening bleeding: emergency hospital management and specialist anticoagulant-reversal protocol. GPs should not independently give vitamin K or prothrombin complex concentrate for epistaxis.

Tranexamic acid

Tranexamic acid may be considered in selected significant or recurrent epistaxis in accordance with the local ENT/emergency protocol. Do not prescribe a universal oral regimen in primary care. Consider thromboembolic history, renal function and the indication for anticoagulation; individualise the decision. Any systemic use should follow the SPC and local specialist advice.

Next steps: see DOACs, antiplatelets and anticoagulation · Hypertension

Pinching soft part of nose compresses Little's area (anterior inferior septum, where most bleeds originate). Pinching bony bridge does nothing — no vessels there. Forward-leaning position prevents blood swallowing (causes nausea, obscures volume assessment). 15 minutes continuous pressure allows platelet plug formation.

Silver nitrate cautery is effective when a discrete bleeding point is visible. Chemical cauterisation coagulates vessel and surrounding tissue, seals bleeding point. Bilateral cautery risks septal perforation (devascularisation → ischaemic necrosis). Allow 4–6 weeks before cauterising the opposite side if needed.

Do not routinely stop anticoagulation for minor controlled epistaxis — thrombotic risk usually outweighs bleeding risk. Identify and treat the source, check INR if on warfarin and discuss abnormal results with the anticoagulation service; major bleeding needs emergency hospital management and a specialist reversal protocol. Discuss with cardiologist before stopping DOACs/warfarin long-term.

Lifestyle

Prevention — Humidification, Naseptin, avoid triggers

Done

Prevent recurrence by moisturising nasal mucosa, avoiding trauma, and managing environmental factors.

Naseptin cream Apply pea-sized amount inside nostrils with little finger four times daily for 10 days (twice daily for up to 2 weeks if adherence is a problem — NICE CKS). Contains chlorhexidine + neomycin (antibacterial) and moisturises septum. Prevents crusting, reduces S. aureus colonisation. CONTRAINDICATED if peanut/soya allergy (contains arachis oil) — check allergy before prescribing. Check the current SPC and local formulary (local first choice). Avoid prolonged or repeated topical antibiotic courses without review.

Non-antibiotic alternatives Simple petroleum jelly or saline moisturisation may be used as a non-antibiotic alternative where appropriate. Mupirocin is not an automatic replacement for Naseptin because of antimicrobial-resistance concerns — use only per local formulary/specialist advice.

Saline nasal spray Sodium chloride 0.9% spray TDS-QDS. Keeps mucosa moist, prevents crusting, thins secretions. Available OTC (Sterimar, Neilmed). Use especially in winter (dry heated air) and air-conditioned environments.

Avoid dry air Avoid dry air where possible; a humidifier may help if practical. Prevents nasal mucosa drying overnight. Particularly important in winter (central heating), air-conditioned offices, low-humidity climates.

Avoid nose picking Main cause of recurrent childhood epistaxis. Trim fingernails short (reduces trauma). Distraction techniques for children. Address underlying cause (allergic rhinitis → itchy nose → picking).

Gentle nose blowing Blow gently, one nostril at a time. Vigorous blowing dislodges clots, increases pressure. Avoid forceful sniffing (can restart bleeding). Use tissues, not handkerchiefs (harbour bacteria).

Treat allergic rhinitis If sneezing/itching triggers bleeds. Intranasal steroid (mometasone, fluticasone) — aim spray AWAY from septum toward turbinates (prevents septal thinning). Antihistamines (cetirizine 10 mg OD) reduce sneezing. Review the need for nasal steroids if bleeding is recurrent.

Avoid triggers Hot showers (vasodilation), alcohol (vasodilation), straining, heavy lifting, bending forward. Avoid OTC NSAIDs/aspirin if possible (impair platelet function); do not routinely stop prescribed secondary-prevention antiplatelet or anticoagulant treatment — discuss with the prescriber if bleeding is clinically significant. Intranasal cocaine and other irritants (vasoconstriction → ischaemia → perforation).

Hydration Encourage normal hydration unless a renal, cardiac or other condition requires fluid restriction. There is no specific fluid target for epistaxis prevention.

First aid education Teach patient/parents correct technique: sit forward, pinch soft part, 10–15 minutes continuous pressure, breathe through the mouth and spit out blood, do NOT tilt head back, do NOT release pressure early to check. Downloadable NHS leaflet available.

Naseptin (chlorhexidine + neomycin) is a local formulary first-choice option — antibacterial with an emollient base that moisturises fragile mucosa. Use a short course; avoid prolonged or repeated courses without review (resistance). Check peanut and soya allergy (contains arachis oil) and the current SPC.

Avoiding dry air — winter central heating and air conditioning dry the mucosa, causing crusting, cracking and bleeding. Saline spray or gel and avoiding dry air where possible are simple measures.

Correct steroid spray technique prevents iatrogenic epistaxis — aim spray AWAY from septum (toward outer wall/turbinates). Spraying directly at septum causes chemical thinning, ulceration, perforation, recurrent bleeding. Right hand for left nostril, left hand for right nostril achieves correct angle. Review the need for nasal steroids if bleeding is recurrent.

Safety

Follow-Up — Monitor recurrence, review anticoagulation, re-refer if red flags

Done

Schedule reviews based on severity. Safety-net for recurrent or severe bleeding.

1 week post-cautery

Phone review: Check eschar healing (falls off 7-10 days), no re-bleeding, Naseptin compliance. If re-bled → examine, re-cauterise if source visible, or refer ENT if no source.

2 weeks (if on Naseptin)

Review after 10-day Naseptin course. Check bleeding stopped, mucosa healed. If recurrent despite Naseptin → refer ENT (may need diathermy cautery or nasoendoscopy to identify source).

1 month (anticoagulated)

Warfarin: check INR when clinically indicated; discuss abnormal results with the anticoagulation service. DOAC: INR does not assess effect. If recurrent clinically significant bleeds → discuss with the prescriber/anticoagulation service rather than stopping. Do not routinely stop secondary-prevention antiplatelets.

3 months (recurrent bleeds)

Review bleeding diary: Frequency, severity, triggers. If bleeds keep recurring despite preventive measures → ENT referral for nasoendoscopy ± diathermy cautery. If HHT suspected → HHT specialist centre referral; check FBC and iron status.

Safety-net 999

Massive bleeding (soaking towels, blood clots size of fist). Haemodynamic compromise (dizziness, collapse, chest pain). Choking on blood (posterior bleed). Bleeding lasting longer than 10–15 minutes despite correct pressure → A&E straight away (999 if heavy, faint or choking on blood).

Safety-net Same-day GP

Bleeds becoming more frequent or heavier. Bleeding despite cautery. New unilateral symptoms (obstruction, facial pain). Easy bruising or petechiae develop. Pallor, fatigue (anaemia from chronic blood loss).

Re-refer ENT if

Recurrent bleeds despite cautery + Naseptin. New unilateral obstruction. Suspected malignancy. No anterior source identified (needs nasoendoscopy). Septal perforation enlarging or symptomatic (whistling, crusting).

Post-cautery follow-up ensures healing and identifies treatment failure. Silver nitrate creates black eschar (coagulated tissue) which falls off in 7-10 days, revealing healed pink mucosa underneath. If re-bleeding occurs = either incomplete cautery (missed bleeding point) or new bleeding site. Re-examine and re-cauterise if source visible.

Chronic blood loss causes iron-deficiency anaemia — even small frequent nosebleeds can cause iron deficiency. Check FBC and iron status in recurrent bleeding. Treat with oral iron (e.g. ferrous sulfate 200 mg once daily; alternate days if not tolerated — BSG 2021), but also identify and treat bleeding source (cautery, Naseptin).

HHT requires specialist centre input — not managed in primary care. Visceral AVM screening is arranged through the HHT specialist centre, not by the GP; coordinated ENT, respiratory, hepatology, neurology and genetics input may be needed. Pulmonary AVMs cause paradoxical emboli — treatable with coil embolisation. Bevacizumab (anti-VEGF) reduces epistaxis severity in severe HHT.