Epistaxis (or a nosebleed) is bleeding from the nostril/s, nasal cavity and/or nasopharynx [mfn referencenumber=”1″]Alexiou A. Epistaxis. BMJ Best Practice [Internet]. London: BMJ Publishing Group; 2021 [cited 2021 August 28]. Available from: https://bestpractice.bmj.com [/mfn]

Classified: anterior or posterior bleed [mfn referencenumber=”1″]Alexiou A. Epistaxis. BMJ Best Practice [Internet]. London: BMJ Publishing Group; 2021 [cited 2021 August 28]. Available from: https://bestpractice.bmj.com [/mfn]

• Anterior: most common, usually self-limiting
• Posterior: can result in significant bleeding, may require urgent referral to ENT

Prioritise: massive haemorrhage, persistent or prolonged epistaxisMassive haemorrhage: bleeding causing tachycardia of HR >110 bpm and/or SBP <90 mmHg (from British Committee for Standards in Haematology)

Emergency: acute massive haemorrhage with signs of airway or haemodynamic compromise

Within 30 mins: persistent or prolonged epistaxis 

Within hours: others

Referrals to ENT if: post ENT surgery (ensure no post operative complications), massive haemorrhage, intractable bleeding, posterior bleeding, at risk groups with difficult to control bleeding e.g. children [mfn referencenumber=”1″]Alexiou A. Epistaxis. BMJ Best Practice [Internet]. London: BMJ Publishing Group; 2021 [cited 2021 August 28]. Available from: https://bestpractice.bmj.com [/mfn], bilateral nasal packing required [mfn referencenumber=”1″]Alexiou A. Epistaxis. BMJ Best Practice [Internet]. London: BMJ Publishing Group; 2021 [cited 2021 August 28]. Available from: https://bestpractice.bmj.com [/mfn]

Trauma: including nose picking, insertion of NGT, facial injuries (e.g. MVA)

Dry or non-humidified air e.g. nasal prongs (causes dry mucosa and mucosal irritation)

Rhinitis [mfn referencenumber=”1″]Alexiou A. Epistaxis. BMJ Best Practice [Internet]. London: BMJ Publishing Group; 2021 [cited 2021 August 28]. Available from: https://bestpractice.bmj.com [/mfn]

Neoplasm (rare) [mfn referencenumber=”1″]Alexiou A. Epistaxis. BMJ Best Practice [Internet]. London: BMJ Publishing Group; 2021 [cited 2021 August 28]. Available from: https://bestpractice.bmj.com [/mfn] [mfn referencenumber=”2″]Alter H. Approach to the adult with epistaxis. In: Woldson AB, Deschler DG, editors. UpToDate [Internet]. Waltham (MA): UpToDate Inc; 2021 [cited 2021 August 28]. Available from: https://www.uptodate.com  [/mfn]

Bleeding may be exacerbated by: use of anticoagulation/antiplatelets, underlying bleeding disorders or vascular conditions

History:

• Bleeding from 1 or both nostrils, post nasal drip of blood
• Distinguish from haemoptysis and haematemesis 
• Symptoms of anaemia and hypovolaemia (ascertain severity of bleed)
• Identify any risk factors (esp use of anticoagulants or antiplatelets)

Examination key points:

• Ensure vitally stable, focusing on airway assessment [mfn referencenumber=”2″]Alter H. Approach to the adult with epistaxis. In: Woldson AB, Deschler DG, editors. UpToDate [Internet]. Waltham (MA): UpToDate Inc; 2021 [cited 2021 August 28]. Available from: https://www.uptodate.com  [/mfn]
• Check for active bleeding/clots in oropharynx (esp in prolonged epistaxis)
• Signs of anaemia
• If able, examine nose to identify source of bleeding (anterior bleed vs posterior bleed)
  • Equipment: vasoconstrictive/local anesthetic nasal spray, nasal speculum, nasal forceps, suction catheter (Yankuer sucker or Frazier sucker)

Initial investigations

Investigation	Significance
VBG	Hb check

Further investigations (1)

Investigation	Indication
FBE	Hb check- ?anaemiaPlatelets- ?ITP or other haematological issues
Group + hold	Esp if massive haemorrhage or prolonged epistaxis, or high risk groups (e.g. frail + elderly, coagulopathic)
UEC	Check for renal function (in case contrast required for further investigations or management)
Coags	If on anticoagulants, to check for coagulopathy (patients with CLD or CKD at risk), handy if interventional radiology required (e.g. angioembolisation)
LFT	Check for underlying liver disease (increases risk of coagulopathy)
CT angiography*	Identification of bleeding vessel for ?suitability of angioembolisation

By location of bleed:

• Anterior bleed: most common, mostly occurring in Little’s area (site of anastomoses of 3 vessels) and most often self-limiting
• Posterior bleed: arises from arteries in posterior nasal cavity or nasopharynx (e.g. sphenopalatine and carotid arteries), can result in significant bleeding and will require urgent escalation to ENT
  • Suspicious if: significant bleeding with risk of airway compromise, continuous blood dripping down posterior oropharynx, bleeding from both nostrils, anterior site of bleed unable to be identified (4)

By amount of bleeding:

• Major haemorrhage defined as bleeding causing tachycardia of HR >110 bpm and/or SBP <90 mmHg (from British Committee for Standards in Haematology)

Resuscitation and escalation:

• resuscitative measures
  • Suction clot/blood (compromise due to airway obstruction)
• Activate local hospital major haemorrhage protocol (1)
• Urgent referral to ENT (1)

Nasal first aid: 

• Pinching nose (cartilaginous part of nose, below bridge) for at least 10 mins (1,3)

• Sit patient upright, leaning forward (prevent blood from trickling behind into the naso-pharyngeal/oro-pharyngeal space)

• Encourage patient spit blood out instead of swallowing (better estimation of blood loss and less irritative for stomach)

Transfusions to consider (although management will the largely guided by reg/ENT):

• Blood transfusion 
• FFP, platelet transfusion DRS ABCD: escalate to code blue if any signs of airway compromise and initiate 

Equipment that may be required: (?call out box with images – see Appendix of images)

• Vasoconstrictor +/- local anaesthetic nasal spray (e.g. co-phenylcaine spray) and nozzle
• Nasal speculum
• Nasal forceps (e.g. Bayonet forceps)
• Suction catheter (Yankuer or Fraizier suckers)
• Nasal packing of choice (e.g. cotton wool, ribbon gauze, kaltostat, merocel pack, Rapid Rhino- will also require sterile water, 10-20mL syringe)
• Nasal bolster (for patient comfort)
• Blueys/tissues 

Anterior bleeds

1. Nasal first aid as above (?call out box) +/- proceed with below steps if ongoing bleeding
2. Cautery (seek assistance if unsure): usually with silver nitrate 

• Clean nose with sucker or cotton buds
• Apply local anaesthetic nasal spray
• Proceed if site of bleeding able to be identified
• Put silver nitrate stick to bleeding site/vessel, rolling it around until bleeding area is covered. Area will become white/silver, appearing like a shallow ulcer.
• Video demonstration: https://vimeo.com/royalchildrenshospital/review/112879843/838c64608a (3)

Persistent epistaxis/site of bleed unable to be identified:

Nasal packing

1. Application of vasoconstrictor +/- local anaesthetic nasal spray (e.g. co-phenylcaine spray)

• Clear nose first if obstructed with blood clots (suction or ask patient to blow nose)
• Sprays can be applied: directly into nose or via soaking nasal packing material (e.g. cotton wool, ribbon gauze, kaltostat)

2. Inserting packing agent of choice (ribbon gauze, kaltostat, merocel pack), starting on the floor of nasal cavity (2):

E.g. Rapid Rhino:

• Method: vasoconstrictive/local anaesthetic nasal spray, clear nasal cavity if obstructed with blood clots, soak Rapid Rhino in sterile water, slide Rapid Rhino along floor of nasal cavity until entirety of fabric ring within nasal cavity, inflate with 20mL air (or until cuff is round and firm) (1, 2)
• Removal: typically retain pack for 1-2 days. Removal involves deflation of balloon, observation for persisting bleeding, then removal of Rapid Rhino 
• Video demonstration: ​​https://www.youtube.com/watch?v=Gn7DX7BqbtI (5)

3. Suspend anticoagulation/antiplatelets if clinically appropriate – if unsure, consult registrar
4. Symptomatic management:

• Analgesia
• Anti-emetics (may become nauseous if large amounts of blood ingested)

5. Consider referral to ENT if persistent bleeding 
6. Optional: nasal bolster for patient comfort

Posterior bleeds

1. Urgent referral to ENT; observe closely as posterior bleeds likely to be significant and patient at risk of deterioration
2. Position patient upright and leaning forward
3. Nasal first aid and nasal packing in the interim +/- Rapid Rhino for tamponade
4. Symptomatic management

Pharmacological considerations:

1. Prophylactic antibiotics

• Indications for use:

• Patients at risk of infection (e.g. diabetics, elderly, immunosuppressed)
• Prolonged nasal packing likely required > 48 hours (esp with rapid rhino)
• Guided by ENT

Cefazolin* 2g IV daily for duration of packing (or per ENT)or Cefalexin* 250mg PO QID for duration of packing (or per ENT)

(6,7)

2. Tranexamic acid

• IV dose as below, or topically as tranexamic acid soaked gauze during nasal packing
• Indications: refractory bleeding (2)
• Guided by ENT 

Tranexamic acid* 1g IV, then 500mg PO TDS for 3-5 days

(6,7)