2.  Very common  Usually self limiting  Rarely massive bleeding can be fatal

3.  To understand the causes and predisposing factors  To consider assessment and management  To review complications

4.  Is bleeding from the nose caused by damage to blood vessels of nasal mucosa  Anterior (80-90%), Little’s area anterior nasal septum – Keisselbach plexus of vessels  Posterior from branches of sphenopalatine artery in posterior nasal cavity

5.  60% of population  6% seek medical attention  Peaks – 2-10 years greater than 45 years – posterior epistaxis more common in older people  Under 2 years rare and may be associated with injury or underlying serious illness

6.  Nosepicking  Nasal fractures  Septal ulcers / perforation  Foreign body  Blunt trauma e.g. falls

7.  Infection  Allergic rhinosinusitis  Nasal polyps

8.  Topical drugs-cocaine, nasal decongestants  Vascular –hereditary haemorrhagic telangiectasia  Wegeners granulomatosis  Post-operative – ENT, max fax, ophthalmic

9.  Benign tumours – angiofibroma  Malignant tumours – squamous cell  Nasal oxygen

10.  Hypertension  Atherosclerosis  Increased venous pressure from mitral stenosis  Alcohol  Environmental – temperature, humidity, altitude

11.  Thrombocytopaenia  Platelet dysfunction  Leukaemia  Haemophilia  Anticoagulant drugs  Antiplatelet drugs e.g aspirin, clopidogrel

12.  Most self-limiting and do not require medical treatment  Transfusion unusual  Massive bleeding rare but can be fatal

13.  ABC  resuscitation as required

14.  Lean forward (decreases blood flow through nasopharynx)  Open mouth, spit blood into bowl, minimises swallowing  Pinch soft part of nose for 10-15 minutes CONTINUOUSLY

15.  Duration  Which nostril  Estimated blood loss  Any home management / packing  Previous epistaxis and management  PMH –likely underlying causes

16.  Surgery  Trauma  Symptoms suggestive of tumour ◦ Nasal obstruction ◦ Rhinorrhoea ◦ Facial pain ◦ Facial numbness, double vision

17.  Drugs  FH bleeding disorders  environmental

18.  ABC  General examination  Local examination  Light source and nasal speculum  Get patient to blow nose ( dark blood or clots likely to be old)  Look for bleeding point ( if bleeding stopped, small red dot < 1mm)

19.  Profuse bleeding from both nostrils with no visible bleeding point on speculum examination suggests posterior bleed

20.  FBC if heavy or recurrent bleeding or clinically anaemic (often not required)  Coagulation – if on warfarin or bleeding diathesis suspected  Group and save / cross match - if bleeding heavy, shock, severe anaemia

21.  Naseptin (chlorhexidine and neomycin) qds for 10 days  Avoid in peanut allergy – use mupirocin instead  Reduces crusting and vestibulitis  Very useful in young children as cautery inappropriate

22.  Use if first aid unsuccessful, not for young children  Need appropriate expertise and equipment  Blow nose  Anaesthetic spray preferably with vasoconstrictor (eg lignocaine and phenylephrine)  Allow 3-4 mins for anaesthetic to work

23.  Identify bleeding point  Apply silver nitrate stick to bleeding point for 3-10 seconds until grey-white colour develops  Only one side of septum to avoid septal perforation  Avoid touching area not requiring treatment

24.  Dab cauterised area with clean cotton bud to remove chemical or blood  Naseptin or mupirocin cream  Self care advice

25.  Avoid blowing or picking nose  Avoid heavy lifting  Avoid strenuous exercise  Avoid lying flat  Avoid alcohol and hot drinks ( cause vasodilation)  If further bleeding unresponsive to first aid measures, return to ED

26.  If bleeding not controlled  Local anaesthetic and vasoconstrictor  Nasal tampon (merocel)  Inflatable packs (rapid rhino)  Impregnated ribbon gauze – needs specific expertise

27.  Position sitting forward mouth open  Secure pack to cheek  Check no pressure on cartilage around nostril  Check oropharynx for bleeding, may need to pack both nostrils  Admit ENT

28.  Sinusitis  Septal haematoma /abscess (from traumatic packing)  Pressure necrosis (from excessively tight packing)  Toxic shock syndrome (prolonged packing)  Airway obstruction

29.  Uncontrolled bleeding  Posterior bleeding  Nasal pack  Significant comorbidities clotting disorder, anaemia  Recurrent with high risk of underlying cause

30.  Formal packing  Endoscopy and electrocautery  EUA and surgical intervention e.g. Arterial ligation  Radiological arterial embolisation  IV or oral tranexamic acid

31.  History and examination  Consider underlying cause  Refer children under 2 years for further investigation  Manage with topical antiseptic or nasal cautery  Refer if epistaxis not settled or high risk of serious underlying cause

32.  Reference – NICE 2010

33.  ABC and resuscitation plus first aid measures  History – and consideration of underlying cause  Examination local /general  Investigation where appropriate  Management  Referral to ENT