Epistaxis

Objectives

To guide the assessment and management of patients presenting to medical facilities with acute epistaxis.

Scope

This guideline includes a stepwise approach to assessing and managing a patient with acute epistaxis, from minor to severe. A description of the two main sites of epistaxis is included to aid understanding of targeted management.

The contraindications, cautions, and approaches to both nasal cautery and nasal packing are described.

This guideline covers the control of epistaxis but does not describe the general management of a patient with haemodynamic instability - for this, see guidelines on Immediate Management of the Shocked Patient and on Emergency Transfusion. 

Audience

This guideline is intended for use of registered healthcare professionals fulfilling a general role in a forward medical location or in an Emergency Department on deployed operations.

Initial Assessment & Management

If the patient is haemodynamically unstable, apply epistaxis first aid measures as detailed while concurrently resuscitating as per guidelines on management of shock, including emergency transfusion if required. Give tranexamic acid (1g IV/IO) and if available, insert nasal packing as soon as possible.

If the patient is haemodynamically stable:

First aid measures:

  • First aid measures should resolve most bleeds.
  • Ensure patient sat up with head leaning forward over bowl to reduce blood draining to throat.
  • Patient to breathe through mouth.
  • Pinch the fleshy part of the nose firmly (not the nasal bones), closing the nostrils.
  • Hold the nose in this position for 20 minutes without releasing pressure.
  • Encourage the patient to spit out any blood in the mouth into bowl.
  • If available, patient can suck on ice or place ice packs on forehead, back of neck and/or bridge of nose. This helps to constrict the flow of blood.
Use epistaxis first aid measures without pause for 20 mins to control bleeding. These measures should resolve most episodes of epistaxis.

Nasal cautery:

  • If ongoing epistaxis after 20 minutes of first aid measures, then examine both nasal cavities to identify source.
  • This may be difficult with ongoing bleeding. Any loose clot may need to be removed with forceps.
  • Nasal cauterisation should be performed as detailed below.
Nasal cauterisation is only appropriate if there is a visible bleeding point and clinician is trained to perform the procedure.

If cauterisation/packing are not available, continue ongoing first aid measures until bleeding resolves or patient can be evacuated to an area where these resources are available, while monitoring the patient for signs of haemodynamic instability.

Advanced Assessment & Management

If nasal cautery is not effective, not available, or bleeding point is not visible then next step is to insert nasal packing, as detailed below. Equipment required is likely to only be available at higher levels of care.

Topical application of tranexamic acid for epistaxis has not been shown to be of benefit in controlling epistaxis and is therefore not recommended. 

Prolonged Casualty Care

Once bleeding is controlled:

  • Advise that the patient should avoid activities that increase bleeding for the next 24 hours. These include:
    • Blowing or picking the nose
    • Heavy lifting
    • Strenuous exercise
    • Lying flat
    • Drinking alcohol or hot drinks
  • Give advice on first aid measures to manage any potential ongoing bleeding.

If nasal packing was inserted:

  • Ensure adequate pain relief is provided as per pain management guideline.
  • Packing should only remain in place for 24-48 hours.
  • Antibiotics are not normally required. However, consider antibiotic use if prolonged packing (>48 hours in situ) is unavoidable.

 

Paediatric Considerations

  • Consider whether nasal foreign body present.
  • Algorithm is the same as adults. Nasal cautery is not contraindicated in paediatric patients.
  • Nasal packing is poorly tolerated in paediatric patients and typically requires topical anaesthetic as well as IV analgesia.

Anterior and Posterior Epistaxis

Identifying the type of bleed in epistaxis is helpful to steer ongoing management should first aid measures prove to be ineffective.

Anterior epistaxis is more common, especially in children and young adults, and is easier to manage. These bleeds typically occur from Little’s area (Kiesselbach plexus) and are typically associated with trauma but also with dryness of the nasal mucosa that may be associated with operational activity in certain environments.

Posterior epistaxis is much less common (accounting for around 10% of bleeds in all populations) and is more challenging to manage. These bleeds originate from the posterior nasal cavity and may be associated with hypertension or atherosclerosis.

Posterior bleeds may be difficult to control even if nasal packing is available - if bleeding is ongoing, monitor closely for haemodynamic instability and consider early evacuation if possible and/or specialist ENT support via reachback.

 

Nasal Cauterisation Procedure

Nasal cauterisation is contraindicated if the bleeding source not visible. Check allergies as contraindications also include known allergy to silver nitrate.Never cauterise both sides of the nasal septum simultaneously, as this can lead to septal perforation. An interval of at least four and ideally six weeks should elapse before cauterisation of the other side of the septum is attempted.

Method:

  • Wear headtorch or source assistance for lighting.
  • Ensure bleeding point is visible. If available, use nasal speculum or press upwards with own finger on nasal tip to improve visualisation.
  • Remove excess blood and large clots as able to improve visualisation.
  • Apply topical anaesthetic (phenylephrine/xylocaine spray) to nasal mucosa. This also helps constrict the blood vessels to aid with visualisation. Two alternative application methods:
    • Sprayed directly onto nasal mucosa at site of bleeding.
    • Gauze soaked in the liquid can be temporarily placed in nasal cavity on site of bleeding. Pinch the fleshy part of nose externally after insertion for a short period while soaked gauze is in nose. Remove gauze before applying nasal cautery.
  • Apply cautery stick to nasal mucosa bleeding point using a gentle rolling motion for 5-10 seconds. This will result in a grey/dark residue.
  • Dispose of nasal cautery stick.
  • Reassess for active bleeding without disturbing area of cautery.

Cautions: Do not exceed 10 seconds cauterisation; do not cauterise the same area repeatedly; do not attempt to cauterise large areas.

Some residual bleeding is expected. Continued first aid measures for a short period following cauterisation may be sufficient to resolve any residual epistaxis. If excessive bleeding persists despite this, consider nasal packing if available.

Nasal Packing Procedure

Contraindications to nasal packing include significant facial or nasal bone fractures, and suspected base of skull fractures.

Nasal packing is likely to cause significant discomfort, may cause trauma to the nasal mucosa and is likely to require longer ongoing management. This intervention should therefore be reserved for patients in whom first aid measures have been unsuccessful and nasal cautery is not possible or has proven ineffective.

  • Pushing any form of nasal packing further into the nose may push a clot posteriorly that falls into the mouth. It is helpful to warn the patient this may occur and/or attempt to remove the clots with forceps, if available, prior to insertion.

Consult manufacturer guidelines if available.

 

Anterior Packing: Rapid Rhino™

The standard Rapid Rhino™ device is intended for anterior packing. The device is available in different lengths ranging from 4.5 - 7.5cm. Be aware that there is a separate, longer (9cm) device available for packing posterior epistaxis.

To insert the standard anterior device:

  • Remove the protective cover.
  • Soak the device in sterile water for 30 seconds.
  • Insert the pack into the nostril parallel to septal floor, until the marker is just inside the nostril.
  • Use a 20ml syringe to slowly inflate the device with air until the pilot cuff becomes rounded and feels firm.
  • Observe for 30 minutes after insertion to ensure that no further leakage occurs, either from the nose or posteriorly into the oropharynx.

If bleeding does not resolve from insertion of a Rapid Rhino™ into the bleeding nostril, then consider:

  • Further inflating the device.
  • Continuing with ice packs on nose bridge, forehead, and nape of neck.
  • Insertion of a second device into the contralateral nostril. The first device may need to be partially deflated to allow insertion of the second device. Re-inflate after insertion.

Removal method:

  • Nasal packing should remain for 24 hours before attempting removal.
  • When ready for removal, deflate the Rapid Rhino but do not remove it immediately.
  • Assess for bleeding
  • If no active bleeding, then gently remove the Rapid Rhino. Ensure it is fully deflated prior to removal.

 

Anterior Packing: Nasal Tampons (e.g. Merocel™)

These devices take the form of a dehydrated compressed sponge. They are generally similarly effective to Rapid Rhino™ devices but may be more uncomfortable during insertion.

  • If possible apply antiseptic cream to the nasal cavity prior to insertion.
  • Immediately prior to attempting insertion, wet the very tip of the devices sharp edge to allow for a softer cushion.
  • Carefully insert the tampon to insert the pack into the nostril parallel to septal floor.
  • Once inserted, instil 2-3ml of sterile saline or water to facilitate expansion.
  • Secure the tail of the device to the patient's face.

 

Posterior Packing: Poster Rapid Rhino™

Posterior bleeds may be difficult to control even with nasal packing - consider early evacuation if possible and/or specialist ENT support via reachback.

The longer (9cm) posterior Rapid Rhino™ device is inserted in the same way as the anterior device but has two inflatable balloons. Following insertion, identify the posterior balloon (marked with a green striped swallow guard) and inflate first with air only, until the pilot cuff becomes rounded and feels firm. Next inflate the anterior balloon using the same technique.

 

Aftercare following insertion of nasal packing

  • Ensure adequate pain relief
  • Packing should only remain in place for 24-48 hours.
  • Antibiotics are not normally required. However, antibiotic use can be considered if packing is in place for more than 48 hours, or if anticipated to be in place for more than 48 hours.

Last reviewed: 01/04/2026

Next review date: 01/04/2027