QuestionSBA
QuestionChoice
Whilst this may be appropriate management after the bleeding had resolved, it is not appropriate initial treatment.
10017175
e
Prescribe Naseptin cream
QuestionChoice
This increases the risk of aspiration and the pressure being applied to the bridge of the nose does not compress the likely source of the bleed.
10017173
c
Lean backwards and apply pressure to the bridge of their nose of 15 minutes
QuestionChoice
Leaning backwards increases risk of aspirating blood. The patient should lean forwards rather backwards.
10017172
b
Lean backwards and apply pressure to outside of their nose just above the nostrils for 15 minutes
QuestionChoice
Whilst leaning forwards is the correct advice to give, applying pressure to the bridge of the nose does not compress the likely source of the bleed.
10017174
d
Lean forwards and apply pressure to the bridge of their nose of 15 minutes
QuestionChoice
This is the correct initial management of epistaxis. Leaning forwards reduces the risk of aspiration and pinching the outside of the nose just above the nostrils applies pressure to the likely source of bleeding.
10017171
a
Lean forward and apply pressure to pinching the outside of their nose just above the nostrils for 15 minutes
QuestionComment
FYI the nasal bridge is the top of the nose in between the eyebrows.  Look up nasal bridge piercing it helped me remember.
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# Summary
 
Epistaxis refers to nosebleeds, which are a common condition ranging significantly in severity. Many are mild and self-limiting with simple first-aid, however larger bleeds may be life-threatening and require rapid intervention and resuscitation. Contributing factors include trauma (e.g. nose-picking), inflammation, drug use (e.g. cocaine), recent surgery, tumours and bleeding diatheses. Management of epistaxis involves a stepwise approach starting with direct pressure on the cartilaginous part of the nose, cautery, nasal packing, followed by interventions such as arterial embolisation or ligation if bleeding is refractory to other treatments. 
 
# Definition
 
Epistaxis refers to bleeding from the nose - this usually originates from the anterior nasal septum (Little's area and Kiesselbach's plexus specifically) but around 10% of cases are posterior, originating from branches of the sphenopalatine artery. 
 
# Aetiology
 
Most cases of epistaxis are mild and self-limiting, with no specific underlying cause identified. Factors that may contribute to epistaxis include:

- Trauma (e.g. nose-picking, blunt trauma, septal perforations and foreign bodies in the nose)
- Oxygen via nasal cannulae (causes drying and irritation of the nasal mucosa)
- Recent ENT or maxillofacial surgery
- Tumours, either malignant (e.g. squamous cell carcinomas) or benign (e.g. angiofibromas)
- Inflammation (e.g. rhinosinusitis, nasal polyps)
- Alcohol excess
- Illicit drug use e.g. snorting cocaine 
- Medications such as nasal steroids
- Vasculitides (e.g. granulomatosis with polyangiitis)
- Bleeding diatheses (e.g. thrombocytopenia, Von Willebrand disease, haemophilia, antiplatelet or anticoagulant medications)
- Environmental factors e.g. inhaled irritants, temperature and humidity

# Signs and symptoms

The major symptom is nasal bleeding - other signs and symptoms may include:

- Bleeding down the throat (which may present as haemoptysis or haematemesis) - may signify posterior epistaxis
- Bleeding from both nostrils is another sign of possible posterior epistaxis
- Signs and symptoms of haemodynamic instability if blood loss is significant (e.g. tachycardia, pallor, syncope)
- Signs and symptoms of an underlying cause (e.g. nasal obstruction and rhinorrhoea may indicate a tumour or nasal polyps)

# Investigations

In most cases of nosebleeds, no investigations are required.

If bleeding is significant, a **venous blood gas** and **FBC** should be done to look for anaemia and thrombocytopenia, a **clotting screen** looking for coagulopathy and a **group and save** or **crossmatch** if blood transfusion is required.

Investigations may also be required if an underlying serious cause is suspected, e.g. imaging or flexible nasendoscopy for a suspected tumour, or specific blood tests for bleeding disorders such as Von Willebrand disease.

# Management

- The first step in management is **direct compression**.
- The patient should sit forward (minimising bleeding into the nasopharynx), breathing through their mouth, and pinch the cartilaginous part of the nose for 10-15 minutes. 
- Sucking ice cubes, cold drinks or placing an ice pack on the back of the neck can help to reduce bleeding.
- This is sufficient to resolve the majority of anterior epistaxis.
- A **topic antiseptic** (e.g. Naseptin or mupirocin) may be prescribed to reduce crusting and rebleeding.
- If direct compression does not resolve the epistaxis and a bleeding point can be visualised, **cautery** may be performed. 
- This involves applying a local anaesthetic spray with a vasoconstrictor (e.g. lidocaine with phenylephrine) to temporarily halt bleeding, then apply silver nitrate (chemical cautery) or electrocautery to the area. 
- Only one side of the septum should be cauterised to avoid perforation.
- If a bleeding point cannot be visualised or bleeding continues despite cautery, **nasal packing** may be used. 
- The most common devices used are nasal tampons (e.g. Merocel) or inflatable packs (e.g. Rapid-Rhino). 
- Both nostrils can be packed to increase pressure on the area of bleeding.
- In cases of posterior epistaxis, **posterior packing** may be required which may involve insertion of a Foley catheter with the balloon inflated to compress the bleeding area.
- Packing should be left in place for 24-48 hours to ensure bleeding has stopped.
- If bleeding continues despite packing, a **surgical approach** may be required (e.g examination under anaesthesia with ligation of bleeding vessels) or interventional radiology may perform an **embolisation**.
- **Tranexamic acid** should be given to all patients with severe bleeding.
- Antiplatelets and anticoagulants should usually be held - may need speciality input (e.g. cardiology) in difficult cases such as patients with metallic heart valves.
- Anticoagulation may need to be reversed with haematology input if needed.
- Patients who are haemodynamically unstable may need resuscitation and blood transfusion.

# Complications

- Anaemia
- Recurrent epistaxis
- Hypovolaemia
- Aspiration of blood and airway compromise
- Nasal cautery may cause septal perforation
- Nasal packing may lead to sinusitis, septal haematoma or pressure necrosis

# NICE Guidelines

[NICE CKS - Epistaxis](https://cks.nice.org.uk/topics/epistaxis-nosebleeds/)

# References

[ENT UK - Epistaxis Guideline](https://www.entuk.org/_userfiles/pages/files/guidelines/global%20ent%20guidelines/nosebleeds.pdf)
 
[Life in the Fast Lane - Epistaxis](https://litfl.com/a-case-of-epistaxis/)

[Patient UK - Epistaxis](https://patient.info/doctor/nosebleed-epistaxis-pro)
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For managing epistaxis, advise the patient to lean forward and pinch the nose for 15 minutes to control bleeding effectively.
An 85-year-old male has a unilateral nosebleed. He denies any nasal trauma and does not take any anticoagulation.

What is the most appropriate initial management advice to provide?
a