Epistaxis
Epistaxis (nosebleed) is a common emergency department presentation. Management focuses on immediate haemorrhage control, assessment for haemodynamic compromise, identification of anterior versus posterior bleeding, and correction of reversible haemostatic problems.
Most bleeds are anterior and controllable in the ED; posterior or refractory bleeds usually require ENT input and sometimes operative or radiological intervention.
Classification and relevant anatomy
- Anterior epistaxis: accounts for the majority of presentations (≈95% of hospital presentations). Most commonly arises from Little’s area (Kiesselbach’s plexus) on the anterior cartilaginous septum. It is typically unilateral, visible and accessible for local measures (pressure, cautery, anterior packing).
- Posterior epistaxis: arises from the posterior/superior nasal cavity or nasopharynx - commonly from branches of the sphenopalatine/internal maxillary arterial system. It is more likely in older patients, often bilateral, more severe, and less amenable to simple ED measures.
Initial assessment
- Follow ABCs: assess airway, breathing and circulation while starting haemorrhage control.
- Identify haemodynamic instability/major haemorrhage using local major haemorrhage criteria or national triggers (for example systolic BP <90 mmHg, heart rate >110 bpm, ongoing large-volume bleeding) and escalate early if present (see NICE NG24 and local policy).
- Document anticoagulant and antiplatelet use and time of last dose.
- Check for signs of coagulopathy or septal haematoma - a tender, boggy septal swelling suggests septal haematoma and requires urgent ENT drainage.