Epistaxis is bleeding from the nose, and most episodes come from a network of vessels in the front of the septum (Kiesselbach plexus). Posterior bleeds are less common, harder to control and more frequent in older adults with high blood pressure or on blood thinners.
Key symptoms
- Blood from one nostril, sometimes both
- Blood running down the back of the throat
- Nausea or vomiting of swallowed blood
- Lightheadedness if blood loss is heavy
What you find on exam
- Airway, breathing, circulation; vital signs and signs of shock
- Sit up and lean forward; look inside the nose after clearing clots to find the bleeding point
- Bleeding down the throat despite front pressure suggests a posterior source
- Look for bruising or bleeding elsewhere
Tests
- Usually none for simple anterior bleeds
- Blood count and type and screen if bleeding is heavy
- INR if on warfarin; clotting tests if a bleeding disorder is suspected
Treatment basics
- Firm pressure on the soft part of the nose for 10 to 15 minutes, leaning forward
- Vasoconstrictor spray such as oxymetazoline, then silver nitrate cautery if a vessel is seen
- Anterior packing or a balloon device if bleeding continues; topical tranexamic acid can help
- Posterior bleeding: posterior balloon, ENT and admission
- Prevent recurrence: saline gel or petroleum jelly, humidifier
Red flags
- Signs of shock or heavy bleeding despite packing
- Posterior bleed, or bleeding with a high INR
- Recurrent one-sided bleeding with blockage in a teenage boy (juvenile angiofibroma)
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Related guides
Sources: NASEMSO National Model EMS Clinical Guidelines; NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations. Written by Making Synapses. Making Synapses is not affiliated with these organizations.