Epistaxis (Nosebleed)

Anatomy and Sites of Bleeding

In all age groups except the elderly, the anterior nasal septum is the most common site of bleeding. This area — known as Little's area or Kiesselbach's plexus — is a convergence of five arteries: the anterior ethmoidal artery (from the ophthalmic artery), the posterior ethmoidal artery, the greater palatine artery, the superior labial artery (from the facial artery), and the sphenopalatine artery. The superficial location of this anastomotic network on the septum makes it highly vulnerable to trauma and drying.

A second important site is Woodruff's plexus, located on the posterior lateral wall of the nasal cavity, near the sphenopalatine foramen. The sphenopalatine artery — the terminal branch of the maxillary artery — enters the nose at a point approximately 1 cm inferior and 1 cm anterior to the posterior margin of the middle turbinate. Posterior bleeds originating from Woodruff's plexus or the sphenopalatine artery are more common in the elderly and are often more difficult to control with first-aid measures alone.

Common Causes

• Nose picking (digital trauma) — the most common cause, particularly in children
• Exposure to cold, dry air (reduced temperatures impair ciliary function and dry the nasal mucosa)
• Nasal tumours (rare but important to exclude in recurrent unilateral bleeding)
• Coagulopathy — anticoagulant therapy (warfarin, DOACs), antiplatelet drugs (aspirin, clopidogrel), liver disease, haematological disorders
• Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) — consider in recurrent bilateral bleeds with telangiectasia on lips/tongue

Assessment

In your history, specifically ask about:

• Anticoagulant or antiplatelet therapy (including aspirin, warfarin, DOACs)
• Known haematological disorders (thrombocytopenia, haemophilia, von Willebrand disease)
• Liver disease (which impairs clotting factor synthesis)
• Recent nasal surgery or nasal trauma
• Family history of bleeding disorders
• Side of bleeding and whether it is predominantly anterior or posterior

In your examination, assess haemodynamic stability: pulse, blood pressure, respiratory rate, oxygen saturations. In a significant bleed, insert two large-bore IV cannulae and send blood for FBC, coagulation screen, group and save (or cross-match if actively haemorrhaging).

First Aid (Primary Haemostasis)

Epistaxis is normally self-limiting with correct first-aid technique. Instruct the patient to:

1. Lean forward — this prevents blood from running back into the pharynx, reducing the risk of swallowing blood (which causes nausea and vomiting) and obscuring the volume lost.
2. Pinch the soft part of the nose (the fleshy alar cartilages) firmly against the septum for a minimum of 20 minutes without releasing. Pinching the upper bony bridge does nothing — demonstrate the correct technique to the patient.
3. Apply a cold compress or ice pack (wrapped in a cloth) to the bridge of the nose.
4. Spit out all blood that runs back into the mouth — do not swallow it.

If bleeding continues despite correct first-aid technique, the patient is likely to have a posterior bleed which cannot be controlled with external compression alone.

Management of a Significant Bleed

With a significant bleed, your first priority is patient safety:

• Resuscitate — insert large-bore IV cannulae and replace lost fluid.
• In a heavy bleed, send a group and save (or cross-match) for possible blood transfusion.
• Do not stop anticoagulants unless the INR is grossly elevated and is the primary cause of bleeding. In patients on anticoagulants or with a coagulation defect, attempting to manage bleeding with packing or cautery often worsens the situation by causing additional mucosal trauma. Correcting the underlying coagulopathy medically should take priority.

Examination and Silver Nitrate Cautery

Prepare yourself with: gloves and an apron, a headlight, a Thudichum's nasal speculum (see pictures — note how to hold it with the thumb in the ring and forefinger on the outside, allowing fine control), local anaesthetic spray (Xylocaine — lidocaine 10% spray), a Yankauer sucker, and silver nitrate sticks.

Examine the nose: use the Yankauer sucker to clear blood and identify the bleeding point. You may notice blood pooling from the post-nasal space — aspirating this can confirm whether bleeding is active or has settled.

Once you have identified the bleeding point in the anterior nose:

1. Spray with Xylocaine and allow the patient to spit it out — it tastes unpleasant. Wait 2 to 3 minutes for anaesthesia to take effect.
2. Hold the black end of the silver nitrate stick firmly against the bleeding spot for at least 30 seconds. Do not roll or move it — hold it still. The area will turn white and then black — this is the expected chemical reaction (precipitation of silver chloride).
3. Repeat with a second stick for a further 30 seconds to gain full control.
4. Cauterise the area immediately around the bleeding point with additional sticks to occlude the feeding vessels.

Once bleeding has stopped, prescribe Naseptin cream (chlorhexidine and neomycin in peanut oil — always check for peanut allergy; prescribe Bactroban [mupirocin] as an alternative) to be applied inside the nose twice daily for two weeks. The correct technique for application is to place a small amount on the tip of the little finger, insert it very gently into the entrance of the nostril (do not rub inside the nose), and then rub gently on the outside of the nostril to direct the cream further in. Some elderly patients with very dry nasal mucosa benefit from long-term Vaseline (petroleum jelly) application after the course of Naseptin.

Discharge Advice

• Avoid hot drinks and hot food for two weeks (heat causes vasodilation). Suggest chasing each mouthful with ice-cold water.
• Avoid straining, heavy lifting, and bending down — all of these raise intracranial venous pressure.
• Do not pick, rub, or touch the nose — likened to picking a scab from a healing wound.
• Sneeze with the mouth open; do not blow the nose.

Nasal Packing for Posterior or Uncontrolled Bleeding

If you cannot identify a bleeding point, or the bleed is posterior (arising from Woodruff's plexus or the sphenopalatine artery, on the lateral wall near the post-nasal space), nasal packing is required.

Merocel Pack

A Merocel pack is a compressed foam tampon that expands when moistened with blood or saline, applying direct pressure to the nasal cavity. Technique:

1. Clear the nose with the Yankauer sucker and apply local anaesthetic spray.
2. Use a 10 cm Merocel pack. Hold it by the end with the dark string attached.
3. Hold the pack completely horizontally and push it straight back along the floor of the nose (parallel to the palate), following the nasal septum. Never push upwards — you will jam it against the middle turbinate and it will not go in. The patient will protest; do it firmly and quickly.
4. Ensure the pack is fully inserted — there should be no foam visible outside the nostril. A common mistake is the "walrus sign," where the pack protrudes like a tusk.
5. Check the posterior pharynx to confirm bleeding has stopped.

If only 8 cm packs are available, push them in as deeply as possible. Patients with Merocel packs in situ are almost universally admitted for at least 24 hours — very few departments allow discharge with nasal packing in place.

Rapid Rhino

A Rapid Rhino is an inflatable balloon coated in carboxymethylcellulose (a haemostatic lubricant). Current evidence suggests it is not more effective than Merocel, but it is considerably more comfortable for both patient and doctor to insert. Soak the pack in water for at least 30 seconds to activate the lubricant. Insert as for Merocel. When correctly positioned, inflate the balloon with air (not saline) — approximately 5 to 7 ml.

Bilateral Packing

Some clinicians insert a Merocel in both nostrils to compress the septum from both sides. Since posterior bleeds arise from the lateral wall rather than the septum, the physiological rationale is debatable, but it is practised widely.

Escalation for Refractory Posterior Bleeding

If nasal packing fails, you are now in specialist territory and must involve a senior ENT or emergency physician. Standard escalation involves:

1. Posterior balloon tamponade: A small female urinary catheter (10 Fr) is passed along the floor of the nose until it enters the post-nasal space, then the balloon is inflated (approximately 7 to 10 ml of water) to prevent blood from flowing into the oropharynx. BIPP (bismuth iodoform paraffin paste) ribbon gauze is then packed layer by layer into the anterior nasal cavity using Tilley's forceps (see picture). This is extremely painful and distressing if performed without adequate preparation — always seek senior assistance.
2. Sphenopalatine artery (SPA) ligation: Endoscopic surgical ligation of the sphenopalatine artery is performed in theatre and is the most effective intervention for refractory posterior epistaxis.
3. Endovascular embolisation: Angiographic embolisation of the internal maxillary artery and its branches — useful in patients unfit for general anaesthesia.
4. External carotid artery ligation: A last resort if the above measures fail.