• Assess the person and, if possible, identify any underlying cause.
• Offer advice on first aid measures and self-care advice for when an acute episode occurs. See Scenario: Acute epistaxis.
• Discuss management options for recurrent epistaxis.
• Refer the person if treatment in primary care is ineffective, or if a serious underlying cause is suspected.

• Ask the person about:
• Which side the bleeding occurs.
• How much blood is lost during an episode. 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.
• How previous episodes of epistaxis have been treated. Mild episodes usually stop with first aid measures. The need for cautery or packing indicates a more severe bleed.
• Examine both nasal passages (ideally with adequate lighting and a nasal speculum).
• Look for a bleeding point. Bleeding points which have stopped look like a small red dot (less than 1 mm).
• Check for a nasal tumour.
• 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:
• 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).
• Conditions predisposing to bleeding (such as haemophilia or leukaemia).
• Family history of bleeding disorders.
• 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 the person is not at high risk of having a serious cause of epistaxis, discuss treatment options for recurrent epistaxis.
• Topical treatment with antiseptic cream to reduce crusting and vestibulitis. This may be particularly useful in children, as it is easier to tolerate than nasal cautery.
• Prescribe Naseptin^® cream first-line. It 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 peanuts as it contains arachis oil (peanut oil).
• If the person is allergic to peanuts or neomycin, consider prescribing mupirocin nasal ointment. Apply to the nostrils two to three times a day for 5–7 days.
• Nasal cautery is similarly effective to Naseptin^® antiseptic cream, but may be more uncomfortable. Consider it for use in primary care only if:
• The appropriate expertise and facilities (good lighting, topical anaesthetic spray, and nasal speculum) are available.
• The bleeding point can be identified.
• It can be tolerated (for example adults and older children, but not younger children).
• If epistaxis does not improve with antiseptic cream or nasal cautery, consider referral.

• Refer the person to an ear, nose, and throat specialist if:
• Epistaxis episodes do not settle with the treatments available in primary care — further investigation and treatment in secondary care may be required.
• The person has recurrent episodes and is at high risk of having a serious underlying cause. Clinical judgement is required, for example consider referral for:
• 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.

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).