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Epistaxis - Management
How should I assess a person with acute epistaxis?

  • Assess the person's airway, breathing, pulse, and blood pressure.
    • If any are compromised, telephone 999 for an ambulance and advise first aid measures while awaiting its arrival.
  • Usually, the person's airway, breathing, pulse, and blood pressure are not compromised. If the person is otherwise well, ask:
    • When the bleeding started, and from which side.
    • How much blood has been lost. This is difficult to estimate, but establish whether the bleeding is light or heavy. If bleeding is heavy, ask the person how many cups (each equates to approximately 250 mL) they think they have lost. Significant blood loss may necessitate admission to hospital.
    • Whether a temporary pack (such as cotton wool) has been used before seeking medical help. These are not always easily visible, and formal nasal packing can push foreign bodies further into the nose.
    • About any previous episodes of epistaxis and how they were treated.
  • Examine both nasal passages (ideally with adequate lighting and a nasal speculum).
    • If the nose is still bleeding, advise the person to blow their nose to remove clots (several big blows may be required). Old blood is usually darker and runs out in a gush with formed clots, then stops. Fresh bleeding is bright red and drips steadily when the person leans forward.
    • Look for a bleeding point. Bleeding points which have stopped look like a small red dot (less than 1 mm). 
  • Suspect a posterior bleed if bleeding is profuse, from both nostrils, and the bleeding site cannot be identified on speculum examination.
  • Determine if there is an underlying cause, particularly in children younger than 2 years of age as epistaxis is unusual in this group.
  • Laboratory investigations are not usually required unless an underlying cause is suspected.
    • A full blood count should be considered if bleeding has been heavy or recurrent, or anaemia is suspected.
    • Coagulation studies should be requested only if a clotting diathesis is suspected or an INR (international normalized ratio) is required to determine if warfarin treatment needs adjusting.

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