• If the person is haemodynamically compromised, telephone 999 for an emergency ambulance and advise first aid measures while awaiting its arrival.
• If the person is not haemodynamically compromised:
• Advise first aid measures.
• Assess:
• Blood loss.
• The site of bleeding (which nostril, and if it is from the anterior or posterior nasal area).
• What attempts have been made to stop the bleeding before seeking medical help.
• Determine if there is a likely underlying cause or comorbid condition that may influence the decision to refer the person (for example warfarin therapy).
• If bleeding stops with first aid measures, consider topical treatment.
• If bleeding does not stop after 10–15 minutes of pressure and the appropriate expertise and facilities for cautery or packing are not available in primary care, send the person to the Accident and Emergency department immediately.
• If bleeding does not stop after 10–15 minutes of pressure and the appropriate expertise and facilities are available in primary care, consider:
• Nasal cautery — if the bleeding point can be seen.
• Nasal packing — if nasal cautery is ineffective or the bleeding point cannot be seen.
• Consider whether admission is warranted.
• Consider referral to an ear, nose, and throat specialist if epistaxis is recurrent despite treatment, or there is a high risk of a serious underlying cause.
• Offer self-care advice after the bleeding has stopped.

• Advise the person to:
• Sit with their upper body tilted forward and their mouth open. They should avoid lying down, unless they are feeling faint.
• Leaning forward decreases blood flow through the nasopharynx, allows spitting out of blood, and minimizes swallowing blood that drains into the pharynx.
• Pinch the cartilaginous (soft) part of the nose firmly and hold it for 10–15 minutes without releasing the pressure, breathing through their mouth.
• A common misconception is that compression of the nasal bones will help stop bleeding.

• 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.

• Determine whether an underlying cause is likely, by asking about:
• A history of surgery or recent trauma (consider the possibility of non-accidental injury).
• Symptoms suggestive of a tumour (benign or malignant) — including nasal obstruction, rhinorrhoea, facial pain, or evidence of cranial neuropathy (for example facial numbness or double vision).
• Current medications (for example aspirin and warfarin, nasally-administered drugs).
• If the person is taking warfarin, check the INR (international normalized ratio) or admit to hospital if bleeding is difficult to control.
• Conditions predisposing to bleeding (such as haemophilia or leukaemia).
• Family history of bleeding disorders.
• Features of hereditary haemorrhagic telangiectasia that may be evident on examination include telangiectasia on the lips, mucous membranes, and fingers.
• Environmental factors (such as humidity and allergens).
• Have a low threshold for referral in children younger than 2 years of age (underlying cause likely).

• If acute epistaxis settles with first aid measures, consider applying a topical antiseptic preparation, particularly in children for whom cautery is not an option.
• Prescribe Naseptin^® (chlorhexidine and neomycin) cream first-line. Advise that the cream should be applied to the nostrils four times daily for 10 days. If compliance is a problem, experts suggest it can be used twice daily for up to 2 weeks.
• Do not prescribe Naseptin^® for people known to be allergic to peanut as it contains arachis oil (peanut oil).
• If the person is allergic to peanut or neomycin, consider prescribing mupirocin nasal ointment. Advise that it should be applied to the nostrils two to three times a day for 5–7 days.

• Consider nasal cautery in primary care if:
• First aid measures have not worked, and
• The appropriate expertise and facilities are available (good lighting, topical anaesthetic spray, and nasal speculum).
• Prior to cautery
• Ask the person to blow their nose to clear any clots and allow local anaesthetic to be applied. This may restart the bleeding.
• Use topical local anaesthetic spray, preferably with a vasoconstrictor (such as lidocaine with phenylephrine — Co-phenylcaine^®) prior to cauterizing the area. Wait for 3–4 minutes for the full effect. The vasoconstrictor may stop the bleeding, but once the effects have worn off the bleeding may start again.
• To cauterize the bleeding point
• Identify the bleeding point — it looks like a small red dot (less than 1 mm) and may not be actively bleeding.
• Lightly apply the silver nitrate stick to the bleeding point for 3–10 seconds, until a grey-white colour develops.
• Only cauterize one side of the septum to avoid nasal septal perforation.
• Avoid touching areas which do not need treatment (for example facial skin, nasal alae).
• After cautery
• Dab the cauterized area with a clean cotton bud to remove excess chemical or blood.
• Apply antibiotic ointment to the area.
• Use Naseptin^® (chlorhexidine and neomycin) cream first-line, applied to the nostrils four times daily for 10 days. Do not prescribe Naseptin^® for people known to be allergic to peanut as it contains arachis oil (peanut oil).
• If the person is allergic to peanut or neomycin, consider using mupirocin nasal ointment. This should be applied to the nostrils two to three times a day for 5–7 days.
• Do not routinely pack the affected side.
• Offer self-care advice.

• Consider nasal packing in primary care if:
• Nasal cautery has been ineffective or the bleeding point cannot be seen, and
• The appropriate expertise and facilities are available (good lighting, topical anaesthetic spray, and nasal speculum).
• Anaesthetize the nasal cavity with topical local anaesthetic spray, preferably with a vasoconstrictor (such as lidocaine with phenylephrine — Co-phenylcaine^®), if this has not already been done. Wait for 3–4 minutes for the full effect.
• The decision concerning which product to use is based on availability, cost, and preference. The available products include:
• Nasal tampons (for example Merocel^®) — effective and easy to use.
• Inflatable packs (for example Rapid-Rhino^®) — effective, and may be more comfortable to insert and remove than nasal tampons. They may also be easier for the healthcare professional to use than nasal tampons.
• Ribbon gauze impregnated with Vaseline^® or bismuth-iodoform paraffin paste — packing with ribbon gauze is not recommended in primary care without specific training.
• Insert the packing according to the manufacturers instructions.
• Pack the person's nostril whilst they are sitting with their head tilted forwards and holding a receptacle allowing them to spit out blood, and breathing through their mouth.
• Secure the pack (for example Merocel^® packs have a string attached which can be taped to the cheek) and ensure there is no pressure on the cartilage around the nostril as this can cause a cosmetic defect.
• Check the oropharynx for signs of bleeding from the back of the nose. If bleeding is seen, consider packing the other side to increase pressure on the bleeding vessel.
• Admit the person to hospital for observation, preferably to an ear, nose, and throat ward.

• Admit the person to hospital if:
• Epistaxis continues despite efforts to stop the bleeding.
• Bleeding from the posterior area of the nose is suspected.
• A nasal pack has been inserted in primary care.
• Consider admission to hospital if the person is elderly or has a comorbid condition (such as coronary artery disease, severe hypertension, clotting disorder, or significant anaemia).
• Consider referral to an ear, nose, and throat specialist if the person has recurrent episodes and is at high risk of having a serious underlying cause. Use clinical judgement and consider referral in the following groups:
• Males 12–20 years of age — angiofibroma is possible (but rare).
• Middle-aged people of Chinese origin — due to the high incidence of nasopharyngeal cancer.
• People older than 50 years of age — as nasal, sinus, and nasopharyngeal cancers are more common (although they usually present with associated symptoms).
• People with any symptoms suggestive of cancer — such as nasal obstruction, facial pain, hearing loss, eye symptoms (proptosis or double vision), or palpable neck glands.
• People with a family history of hereditary haemorrhagic telangiectasia and suggestive features upon examination — telangiectasia on the lips, mucous membranes, and fingers.
• People with occupational exposure to wood dust or chemicals.
• Consider referral to a paediatrician for children younger than 2 years of age who present with epistaxis.

• Secondary care treatments for acute epistaxis include:
• Resuscitation — this may include transfusion to replace blood volume and provide coagulation factors.
• Formal packing (may be under general anaesthetic).
• Endoscopic assessment and electrocautery.
• Examination under anaesthesia and surgical intervention (such as diathermy, septal surgery, arterial ligation, laser treatment).
• Radiological arterial embolization.
• Intravenous or oral tranexamic acid.

• For 24 hours after bleeding, where practical, advise the person to avoid activities which may increase the risk of rebleeding. These include:
• Blowing or picking the nose.
• Heavy lifting.
• Strenuous exercise.
• Lying flat.
• Drinking alcohol or hot drinks — as these can cause the nasal blood vessels to dilate and increase the risk of bleeding.
• If the nose has been cauterized, the person should avoid blowing their nose for a few hours to prevent staining of the nostril.
• If bleeding restarts and does not respond to first aid measures, the person should seek medical advice.

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).