Reasoning GP · Algorithm · 1-page summary
Epistaxis (nosebleeds)
For: adults and children with a nosebleed in primary care. Not for: packing, pledgets, posterior bleeds, tranexamic acid or anticoagulant reversal (ENT/emergency protocols). Child under 2 → block 2.
Core rule: most nosebleeds are anterior and stop with correct pressure. But one-sided bleeding with blockage needs urgent ENT to exclude a tumour, and the rare deaths are mostly in elderly anticoagulated patients with heavy or posterior bleeds.
0Stop — call 999 now — before any history
- Massive bleeding or haemodynamic compromise (hypotension, tachycardia, pallor, dizziness); airway compromise or aspiration risk → 999
- Major trauma or suspected skull-base/facial fracture → 999
- Uncontrolled despite correct pressure and local measures, suspected posterior bleed still bleeding, or severe bleeding on significant anticoagulation → 999 / A&E
- While waiting: sit forward, pinch the soft part, spit not swallow. Record the anticoagulant and last DOAC dose time. GPs do not give vitamin K or PCC.
1Triage — after 10–15 min of correct, uninterrupted pressure
| Situation | Action |
|---|---|
| Stopped | Assess (block 3); find the source |
| Still bleeding | Reassess urgently. Active after further pressure and local measures → Same-day ENT / A&E |
| Transfer earlier | Compromise, anticoagulated with significant bleeding, blood in the airway/pharynx, frailty or major comorbidity, or unable to assess safely |
| Posterior signs | Blood entering the pharynx, both nostrils, no visible anterior point (none diagnostic alone) → A&E |
2Screen — one row is enough
- On warfarin, DOAC or antiplatelet, not stopping → Same-day. INR if on warfarin; INR does not assess DOACs.
- Persistent one-sided obstruction, blood-stained discharge or recurrent one-sided bleeds; facial swelling, anosmia, cranial-nerve signs, nasal mass → Urgent ENT (local head and neck pathway). No biopsy or repeated cautery.
- Adolescent male, one-sided obstruction + profuse bleeding (angiofibroma) → Urgent imaging / ENT; no biopsy.
- Bruising, petechiae, bleeding gums, heavy periods → FBC + clotting ≤48 h (consider in adults, offer in children). Child, unexplained petechiae → Immediate specialist
- Child under 2 years → Same-day paediatrics: bleeding disorder or non-accidental injury; follow local safeguarding procedures.
- Recurrent bleeds from both nostrils → Urgent ENT (HHT, systemic cause).
3Assess — once blocks 0–2 are answered
☐ Pulse, BP, postural BP if volume depleted ☐ Anterior rhinoscopy (speculum + headlight): Little's area, perforation, crusting ☐ Oropharynx for blood ☐ Telangiectasia (lips, tongue, fingers), bruising, petechiae, pallor
Bloods only if recurrent or severe, bleeding elsewhere, anticoagulated or coagulopathy suspected; FBC + iron if recurrent. Raised BP → repeat after haemostasis; do not lower it rapidly.
4Classify — only if the screen is negative
- Anterior (Little's area) — commonest; visible one-sided bleed that stops with pressure → primary care.
- Posterior — persists despite anterior measures, blood in the pharynx → A&E (packing or embolisation).
- Secondary — anticoagulant, bleeding disorder, liver disease → treat the cause plus local measures.
- HHT — recurrent bleeds from childhood + telangiectasia and/or family history → HHT specialist centre.
- Uncertain / no source seen — stopped or posterior; say so → ENT nasendoscopy (still bleeding → same-day).
5Treat today — only these
- First aid: sit forward, pinch the soft part (not the bridge) 10–15 min, mouth-breathe, spit out blood; do not release to check.
- Silver nitrate cautery only for a discrete visible anterior point, by a trained, equipped clinician, after co-phenylcaine. Never both sides of the septum at once (4–6 weeks apart); do not force in young children.
- Naseptin four times daily for 10 days — check peanut/soya allergy — or petroleum jelly/saline. Doses: NICE/SPC, BNF, local formulary.
- Anticoagulant/antiplatelet: do not routinely stop for a minor, controlled bleed; discuss with the prescriber if clinically significant.
6Refer — bleeding settled (still bleeding → same-day)
- Recurrent despite cautery or Naseptin, or no anterior source seen → Urgent ENT (nasendoscopy).
- Suspected HHT → HHT specialist centre; check FBC and iron status.
- Prolonged APTT, or bleeding history suggestive even with normal PT/APTT, or family history → haematology.
- Septal perforation enlarging or symptomatic → ENT.
7Never reassure by
- A bleed that has stopped, if an adult has one-sided blockage or discharge.
- A normal FBC or PT/APTT when the history suggests a bleeding disorder.
- A normal INR in a patient taking a DOAC.
- "Nosebleeds are common in children" — not under 2 years.
- High BP as the explanation for the bleed.
- A "refractory" bleed before checking the first-aid technique — but never delay A&E for ongoing bleeding.
8Safety-net — teach first aid, say it, then document it
999 “Call 999 for very heavy bleeding (soaking towels, clots the size of a fist), feeling faint or collapsing, chest pain, or choking on blood.” A&E “Lasting over 10–15 minutes despite pinching correctly — go to A&E straight away.” Same day: “Contact us today if bleeds get more frequent or heavier, bleed after cautery, new one-sided blockage or facial pain, new bruising or spots, or you become pale and tired.”
✓Safe to leave primary care only if — all five, documented
Bleeding stopped; no block 0–2 row applies
Pulse and BP recorded; BP rechecked if raised
Source seen and treated, or ENT route arranged
Anticoagulant reviewed (not routinely stopped); INR if warfarin and indicated
First aid taught, safety-net given; 1-week review after cautery
Summary of the full Reasoning GP epistaxis algorithm, which holds the history, examination, investigation detail and follow-up. Sources: British Rhinological Society consensus (2017); ENT UK Global ENT epistaxis guideline (2023); NICE NG24; MHRA DOAC advice; NICE NG12 (updated April 2026); NICE CKS; local formulary; SPC. Clinical reference — follow local ENT pathways and check doses: NICE/SPC, BNF.