Epistaxis
at the bedside
- airway, breathing, circulation; full vitals, IV access if bleeding heavily
- sit up, lean forward → spit, do not swallow
- pinch → soft lower third of the nose, ≥ 5 min by the clock, no peeking
escalate now if
- blood into the airway, stridor, falling SpO₂, hypotension or tachycardia → severe bleeding, ENT now
- blood running down the throat despite firm compression → possible posterior bleed, ENT now
- still bleeding after compression and a vasoconstrictor → packing, ENT
- on an anticoagulant or antiplatelet, or platelets low → local control first, reverse only if life-threatening
differentials
- local → dry nasal-cannula oxygen or CPAP, NG tube insertion, nose picking, recent nasal surgery
- bleeding tendency → warfarin, DOAC, heparin, antiplatelets, thrombocytopenia, liver disease, uremia, von Willebrand disease
- recurrent → both sides with telangiectasia: HHT; one side only: tumour
- not from the nose → hemoptysis, GI bleed
focused check
- bleeding → side, how long, how much, previous episodes
- drug chart → anticoagulant (last dose), antiplatelets, heparin prophylaxis, nasal oxygen
- history → bleeding disorder, liver or kidney disease, nasal surgery
- look in the nose → after clearing clots, light and speculum: anterior septum is the usual site
- look in the mouth → blood down the back of the throat: posterior or uncontrolled
send now
- CBC → heavy bleeding or on antithrombotics; low platelets → platelet drop
- coagulation → on warfarin or heparin, liver disease, suspected bleeding disorder → coagulation profile
- group and save → heavy bleeding; crossmatch if unstable
treat
step by step
- compression as above, ≥ 5 min, timed
- still bleeding → clear the clots, oxymetazoline 0.05% 2 sprays into the bleeding nostril (or on a cotton pledget), then compress again
- site seen and you are trained → topical lidocaine first, then silver nitrate to the bleeding point only, one side
- still bleeding → anterior packing (ENT if not trained); resorbable if on an anticoagulant or antiplatelet
- bleeding through the pack or down the throat → possible posterior bleed
- high blood pressure → treat pain and anxiety; lowering BP has no proven effect → hypertension
- topical tranexamic acid → not routine (no benefit in NoPAC)
on an anticoagulant, antiplatelet or low platelets
- not life-threatening → local measures first; do not reverse, transfuse or stop the drug; any hold is with the prescribing team
- life-threatening → reverse by drug → coagulation profile; platelets → platelet drop
posterior bleed
- ENT now; posterior packing or a balloon device, usually by ENT
- after posterior packing → monitored bed, continuous SpO₂, care with sedatives
- despite packing → ligation or embolization (ENT, IR)
severe bleeding
- sit up, suction, oxygen; airway at risk → anesthesia now
- two large IV cannulas, crossmatch; fluids, then blood → hemoglobin drop; shock → hypotension, massive hemorrhage
once it stops
- no nose blowing for 24 h; petroleum jelly to the septum
- nasal oxygen → humidify, lowest flow that meets the target
- packing → document type, side, removal plan; recurrent or one-sided: ENT endoscopy
- hand over → side, what stopped it, packing type, hemoglobin and antithrombotic plan, escalation trigger
evidence
| source | type |
|---|---|
| AAO-HNS 2020 · Clinical Practice Guideline: Nosebleed (Epistaxis) ↗︎ | international guideline |
| NoPAC 2021 · topical tranexamic acid in epistaxis ↗︎ | randomized trial |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
free the on-call checklist covers the whole shift on one printable page.
studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.
updated Oct 2026file complaint/epistaxis