Summary
Definition
History and exam
Key diagnostic factors
- blood at one nostril or on both sides of nose
- presence of risk factors
Other diagnostic factors
- bleeding starting at the nares
- recurrent epistaxis
- septal deviation
- bleeding starting in the throat
- signs of haemodynamic compromise
- intranasal polyp
- telangiectasia
Risk factors
- dry weather and low humidity
- septal deviation
- minor nasal trauma
- nasal foreign body
- nasal polyp
- topical nasal drugs
- primary coagulopathy (e.g., haemophilia)
- medication (e.g., aspirin, anticoagulant, non-steroidal anti-inflammatory drugs)
- familial hereditary haemorrhagic telangiectasia
- juvenile nasal angiofibroma
Diagnostic investigations
1st investigations to order
- clinical diagnosis
Investigations to consider
- FBC and ‘group and save
- clotting studies (INR, prothrombin time, activated partial thromboplastin time, platelet function tests)
- urea and electrolytes and serum creatinine
- liver function tests (LFTs)
- CT scan of paranasal sinuses
- ECG
Treatment algorithm
active epistaxis: major haemorrhage
active epistaxis: no major haemorrhage
persistent epistaxis despite initial measures
epistaxis resolved
recurrent epistaxis
Contributors
Expert advisers
Alexander Alexiou, MB, BS, BSc, DCH, FRCEM, DipIMC RSEd
Emergency Medicine Consultant
Barts Health NHS Trust
Physician Response Unit Consultant
London’s Air Ambulance
Royal London Hospital
London
UK
Disclosures
AA declares that he has no competing interests.
Acknowledgements
BMJ Best Practice would like to gratefully acknowledge the previous expert contributor, whose work has been retained in parts of the content:
Darren Pinder, BSc(Hons), MB BChir, MSc(Med Ed), FRCS(ORL)
Consultant ENT Surgeon
Royal United Hospital Bath NHS Trust Bath
UK
Disclosures
DP declares that he has no competing interests.
Peer reviewers
Darren Pinder, BSc(Hons), MB BChir, MSc(Med Ed), FRCS(ORL)
Consultant ENT Surgeon
Royal United Hospital Bath NHS Trust
Bath
UK
Disclosures
DP declares that he has no competing interests.
References
Key articles
National ENT Trainee Research Network. The British Rhinological Society multidisciplinary consensus recommendations on the hospital management of epistaxis. J Laryngol Otol. 2017 Dec;131(12):1142-56. Abstract
ENT UK. Nose bleed (epistaxis): global ENT guideline. March 2023 [internet publication].Full text
ENT UK. Guideline for management of idiopathic epistaxis in adults. March 2019 [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Haemoptysis
- Haematemesis
More DifferentialsGuidelines
- Guideline for management of idiopathic epistaxis in adults
- British Rhinological Society multidisciplinary consensus recommendations on the hospital management of epistaxis
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