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Epistaxis

 

This guideline applies to children and adults.

 

Introduction

Can affect anyone of any age, but most common in children and the elderly. It is frequently recurrent. Although usually benign and self-limiting, it has the potential to be life-threatening if the bleeding is severe and/or the patient is elderly or frail.


 

Red Flag Features

  • Child under the age of 2yo
  • Foreign body, especially button/watch batteries
  • Bleeding disorders or anticoagulation
  • Haematological malignancy
  • Nasal malignancy

This list is not exhaustive.

 


Investigations

Investigations are not routinely required. If appropriate, consider checking:

  • FBC – severe or recurrent nosebleeds, and/or symptomatic of anaemia.
  • Coagulation studies – suspected clotting disorder or patient on warfarin.

 


Management Optimisation

Brief overview:

For further information on the management of epistaxis see:

 

Nasal Packs:

Absorbable nasal packs

  • NasoPore (Stryker, UK) absorbable nasal packs are used locally in the management of epistaxis and post-op sinus surgery.
  • If an absorbable nasal pack is used, these act as a surface haemostat to allow the underlying mucosa to clot and heal. They typically dissolve in up to 2 weeks.
  • These patients  do not necessarily require ENT follow-up if haemodynamically stable, bleeding arrested and no serious underlying cause suspected.

Non-absorbable nasal packs

  • If a non-absorbable nasal pack is used, it is the responsibility of the person inserting the pack to arrange same-day assessment with the ENT first on-call.


 

Advice and Guidance

ENT Advice and Guidance is available in cases of diagnostic uncertainty, suspected nasal malignancy or recurrent epistaxis that fails to respond to conservative management.

Haematology Advice and Guidance is available if a bleeding diathesis is suspected.


 

Referral

Advise or arrange patients to go straight to ED for:

  • Haemodynamically unstable due to blood loss – straight to ED
  • Foreign body:
    • Button/watch batteries should be removed immediately to avoid permanent nasal damage – if not confident/experienced send straight to ED
    • Other types of nasal foreign body discuss with the ENT first on-call

 

Same-day discussion with ENT first on-call if:

  • Epistaxis fails to stop with first aid measures and/or nasal cautery
  • You have inserted a non-absorbable nasal pack
  • Ongoing or recurrence of epistaxis with an absorbable nasal pack

 

Safeguarding Referral

  • Suspected non-accidental injury

 

Urgent ENT Referral

  • Epistaxis that recurs despite an adequate trial of conservative management 

 



Supporting Information

For professionals:

NICE CKS – Epistaxis (nosebleeds)

Patient UK – Nosebleed (epistaxis)

For patients:

NHS – Nosebleed

ENT UK – Nosebleeds (epistaxis)

  

Page Review Information

Review date

18th October 2024

Next review date

18th October 2026

GP speciality lead

Dr Laura Vines

Contributors

Ms Aileen Lambert, Consultant ENT Surgeon

Mr Neil Tan, Consultant ENT Surgeon