Epistaxis: First Aid, Assessment and Definitive Management
Epistaxis means bleeding from the nose. Most episodes arise anteriorly and stop with correct pressure, but posterior or persistent bleeding can threaten the airway and circulation.
Sit the patient forward, pinch the soft part of the nose continuously for 10–15 minutes, encourage mouth breathing and spit out blood. Assess airway and haemodynamic stability.
Learning objectives
- Distinguish anterior from posterior bleeding.
- Give correct first aid and resuscitate severe epistaxis.
- Outline cautery, packing and escalation.
Blood supply and sites
Anterior bleeding commonly arises from Kiesselbach’s area on the anterior septum. Posterior bleeding often involves branches of the sphenopalatine artery and is harder to localise and control. Review nasal anatomy.
| Feature | Anterior | Posterior |
|---|---|---|
| Frequency | Common | Less common |
| Typical patient | Children or younger adults | Older adults, vascular disease |
| Bleeding | Visible from one anterior nostril | Heavy, bilateral or into pharynx |
| Control | Often pressure or cautery | Often packing, admission or surgery |
Causes and risk factors
- Digital trauma, nose blowing, dry or inflamed mucosa.
- Facial injury, foreign body or recent nasal surgery.
- Anticoagulants, antiplatelets, thrombocytopenia or clotting disorders.
- Hypertension may worsen bleeding but is rarely the sole cause.
- Septal abnormality, vascular lesion or tumour, especially with recurrent unilateral bleeding.
Primary assessment
- Airway: clear clots and call for help if protection is threatened.
- Breathing: give oxygen when indicated.
- Circulation: pulse, blood pressure, IV access, blood tests and fluids or blood for major loss.
- Ask about duration, side, trauma, previous episodes, medicines and bleeding history.
- Use light, suction and a nasal speculum after initial control to find the site.
Do not tilt the head back: swallowed blood causes nausea, aspiration risk and masks ongoing loss.
Stepwise management
First aid
- Sit upright and lean forward.
- Pinch the cartilaginous alae firmly against the septum for 10–15 uninterrupted minutes.
- A topical vasoconstrictor may be used by a trained clinician when appropriate.
Cautery
If one anterior point is visible after bleeding slows, chemical cautery such as silver nitrate may be applied with anaesthesia and protection. Avoid extensive bilateral septal cautery because of perforation risk.
Nasal packing
If pressure and suitable cautery fail, insert an appropriate anterior pack. Suspected posterior bleeding may require a posterior device, resuscitation, admission and urgent ENT support. Monitor carefully and follow local policy on analgesia, antibiotics and removal.
Failure of control
ENT management may include endoscopic sphenopalatine artery ligation, other arterial control or embolisation. Correct significant coagulopathy with the responsible team; do not stop prescribed anticoagulants without clinical assessment.
Investigations
Minor isolated anterior bleeds need no routine tests. For severe, recurrent or unexplained bleeding consider full blood count, group and crossmatch, coagulation studies, renal/liver assessment, endoscopy and imaging when trauma, tumour or vascular disease is suspected.
Aftercare and prevention
- Avoid nose picking, forceful blowing, hot drinks, heavy lifting and strenuous exercise for the advised period.
- Use saline gel or prescribed ointment for dry mucosa.
- Treat rhinitis and review medicines, blood pressure and bleeding risk.
- Return urgently for recurrent heavy bleeding, faintness, breathlessness or blood flowing down the throat.
Shock, airway compromise, major trauma, persistent bleeding despite pressure, suspected posterior source, anticoagulation with ongoing bleeding or recurrent unilateral epistaxis requires urgent evaluation.
Key examination points
- Compress the soft nose, not the nasal bones.
- The patient sits forward and spits out blood.
- Resuscitation takes priority over finding the exact vessel.
- Cautery is for a visible, controlled anterior point.
- Posterior or uncontrolled bleeding needs early ENT escalation.
References and further reading
For education only. Follow current emergency, ENT and Uganda Clinical Guidelines.
