Epistaxis

 

This guideline applies to children and adults. 

  

Introduction 

Epistaxis is common, particularly in children and older adults, and is often recurrent.Most cases are benign and self-limiting, but severe bleeding can be life-threatening, particularly in frail or comorbid patients.

 

In scope             

• Epistaxis

 

Not in scope      

• Other ENT conditions

 

Red flag features       

Suggestive of uncontrolled bleeding

• Haemodynamic compromise
• Bleeding >15 minutes despite appropriate first aid
• Posterior bleed features: blood into throat, bilateral bleeding, persistent despite pressure

 

Suggestive of significant underlying cause:

• Recurrent heavy epistaxis
• Known anticoagulation / coagulopathy
• Child <2 years
• Nasal trauma (± septal haematoma)

 

Suggestive of nasal malignancy: (rare - see full guideline)

• Epistaxis associated with new onset nasal obstruction, facial pain, hearing loss, eye symptoms (watering eye, proptosis, diplopia or other visual changes), and/or persistent lymphadenopathy.

 

Investigations required prior to referral

Investigations are not required for acute epistaxis and are not routinely required for recurrent epistaxis. If appropriate, consider checking: 

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

 

Management – acute epistaxis

First aid for acute epistaxis

• Position:
  • Sit upright and lean forward over a bowl or sink; spit blood out
  • Avoid lying down unless light headed/faint.
• Pressure: 
  • Pinch the soft part of the nose firmly between thumb and forefinger — low down and close to the cheekbones
  • Do not pinch the bony bridge; it will not work.
• Timing: 
  • Maintain continuous pressure for at least 5 minutes (time it on a clock).
• Calm measures: 
  • Stay calm and cool — slow deep breaths, suck ice, or use a cool/wet flannel.

 

If haemodynamically unstable:

Immediate 999 transfer

• First aid measures, nasal cautery or packing if equipment and expertise are available

 

If haemodynamically stable:

First aid measures (as above)

If first aid measures fail to stop bleeding after 10-15 minutes

Nasal cautery or packing if equipment and expertise are available

(see nice cks for further information on these procedures)

(NasoPore (Stryker, UK) are the absorbable packs used locally)

If fails to stop bleeding, or

expertise/ equipment unavailable, or

posterior bleed suspected or

packing has been inserted

Discuss with ENT first on call and arrange immediate transfer to hospital

 

If bleeding effectively controlled in primary care with first aid measures or cautery:

• For 24 hours avoid:
  • Blowing or picking the nose.
  • Heavy lifting.
  • Strenuous exercise.
  • Lying flat.
  • Drinking alcohol or hot drinks.

• Review medications:
  • Consider holding aspirin
  • Review clopidogrel and anticoagulants
  • Do not stop clopidogrel early without specialist advice from cardiology
     (e.g. recent coronary stent)

• Consider topical antiseptic for nasal crusting/vestibulitis
  • Naseptin® (chlorhexidine + neomycin): apply to nostrils QDS for 10 days
  • Do not prescribe if allergy to neomycin, peanut, or soya
    
    Note: Naseptin® reformulated in 2023 to remove peanut oil — older stock may still contain it.
  • If allergies: Mupirocin nasal ointment 2–3× daily for 5–7 days is another option
  • Vaseline/paraffin paste can also be used

• Consider intranasal saline spray (Sterimar) or rinse (Neilmed Sinus Rinse)
  
  
• Consider ENT review as per referral criteria below

 

 

Management – recurrent epistaxis

• Advise patient on first aid measures
• Advise patient on activities to avoid following a nose bleed (as above)
• Consider topical antiseptic cream (as above for acute epistaxis)
• Consider nasal cautery if:
  • Appropriate expertise and facilities
  • good lighting, topical anaesthetic spray, nasal speculum
  • Bleeding point can be clearly identified
  • Patient can tolerate the procedure
  • Avoid cautery in young children <4 years
• Consider referral if meets criteria below

 

Referral criteria

Emergency / same day referral

• 999 as above for uncontrolled acute epistaxis
• Same day discussion with ENT first on call if bleeding controlled but:
  • Nasal packing inserted
  • Underlying bleeding disorder or anticoagulant/antiplatelet use
  • Significant co-morbidity (e.g. severe anaemia)
  • Frail or older adults (risk of complications)
• Discuss with paediatric consultant advice line:
  • If child <2yo with nose bleeds, to rule out an underlying cause
  • Also consider the need for a safeguarding referral if their is a suspicion of maltreatment

 

Outpatient ENT Referral (adult and paediatric >2yo)

• Epistaxis that recurs despite an adequate trial of conservative management  

   

References  

• NICE CKS: Management of Acute Epistaxis
• NICE CKS: Management of Recurrent Epistaxis

 

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	15 May 2026
Next review date	15 May 2028
GP speciality lead	Dr Jack Munro Berry
Contributors	Ms Aileen Lambert, Consultant ENT Surgeon Mr Neil Tan, Consultant ENT Surgeon