   Very common Usually self limiting Rarely massive bleeding can be fatal

 To understand the causes and predisposing factors  To consider assessment and management  To review complications

 Is bleeding from the nose caused by damage to blood vessels of nasal mucosa  Anterior (80-90%), Little’s area anterior nasal septum – Keisselbach plexus of vessels  Posterior from branches of sphenopalatine artery in posterior nasal cavity

  60% of population 6% seek medical attention   Peaks – 2-10 years greater than 45 years – posterior epistaxis more common in older people Under 2 years rare and may be associated with injury or underlying serious illness

     Nosepicking Nasal fractures Septal ulcers / perforation Foreign body Blunt trauma e.g. falls

   Infection Allergic rhinosinusitis Nasal polyps

 Topical drugs-cocaine, nasal decongestants   Vascular –hereditary haemorrhagic telangiectasia Wegeners granulomatosis  Post-operative – ENT, max fax, ophthalmic

  Benign tumours – angiofibroma Malignant tumours – squamous cell  Nasal oxygen

     Hypertension Atherosclerosis Increased venous pressure from mitral stenosis Alcohol Environmental – temperature, humidity, altitude

      Thrombocytopaenia Platelet dysfunction Leukaemia Haemophilia Anticoagulant drugs Antiplatelet drugs e.g aspirin, clopidogrel

   Most self-limiting and do not require medical treatment Transfusion unusual Massive bleeding rare but can be fatal

 ABC  resuscitation as required

 Lean forward (decreases blood flow through nasopharynx)  Open mouth, spit blood into bowl, minimises swallowing  Pinch soft part of nose for 10-15 minutes CONTINUOUSLY

      Duration Which nostril Estimated blood loss Any home management / packing Previous epistaxis and management PMH –likely underlying causes

   Surgery Trauma ◦ ◦ ◦ ◦ Symptoms suggestive of tumour Nasal obstruction Rhinorrhoea Facial pain Facial numbness, double vision

   Drugs FH bleeding disorders environmental

      ABC General examination Local examination Light source and nasal speculum Get patient to blow nose ( dark blood or clots likely to be old) Look for bleeding point ( if bleeding stopped , small red dot < 1mm)

 Profuse bleeding from both nostrils with no visible bleeding point on speculum examination suggests posterior bleed

 FBC if heavy or recurrent bleeding or clinically anaemic (often not required)  Coagulation – if on warfarin or bleeding diathesis suspected  Group and save / cross match - if bleeding heavy, shock, severe anaemia

    Naseptin (chlorhexidine and neomycin) qds for 10 days Avoid in peanut allergy – use mupirocin instead Reduces crusting and vestibulitis Very useful in young children as cautery inappropriate

     Use if first aid unsuccessful, not for young children Need appropriate expertise and equipment Blow nose Anaesthetic spray preferably with vasoconstrictor (eg lignocaine and phenylephrine) Allow 3-4 mins for anaesthetic to work

    Identify bleeding point Apply silver nitrate stick to bleeding point for 3-10 seconds until grey-white colour develops Only one side of septum to avoid septal perforation Avoid touching area not requiring treatment

   Dab cauterised area with clean cotton bud to remove chemical or blood Naseptin or mupirocin cream Self care advice

      Avoid blowing or picking nose Avoid heavy lifting Avoid strenuous exercise Avoid lying flat Avoid alcohol and hot drinks ( cause vasodilation) If further bleeding unresponsive to first aid measures, return to ED

  If bleeding not controlled Local anaesthetic and vasoconstrictor  Nasal tampon (merocel)  Inflatable packs (rapid rhino)  Impregnated ribbon gauze – needs specific expertise

     Position sitting forward mouth open Secure pack to cheek Check no pressure on cartilage around nostril Check oropharynx for bleeding, may need to pack both nostrils Admit ENT

     Sinusitis Septal haematoma /abscess (from traumatic packing) Pressure necrosis (from excessively tight packing) Toxic shock syndrome (prolonged packing) Airway obstruction

     Uncontrolled bleeding Posterior bleeding Nasal pack Significant comorbidities clotting disorder, anaemia Recurrent with high risk of underlying cause

     Formal packing Endoscopy and electrocautery EUA and surgical intervention e.g. Arterial ligation Radiological arterial embolisation IV or oral tranexamic acid

     History and examination Consider underlying cause Refer children under 2 years for further investigation Manage with topical antiseptic or nasal cautery Refer if epistaxis not settled or high risk of serious underlying cause

 Reference – NICE 2010

      ABC and resuscitation plus first aid measures History – and consideration of underlying cause Examination local /general Investigation where appropriate Management Referral to ENT