1. Through history and/or physical examination, assess the hemodynamic stability of patients with epistaxis.
  2. While attending to active nose bleeds, recognize and manage excessive anxiety in the patient and accompanying family.
  3. In a patient with an active or recent nosebleed, obtain a focused history to identify possible etiologies (e.g., recent trauma, recent respiratory tract infection, medications).
  4. In a patient with an active or recent nosebleed:
    1. Look for and identify anterior bleeding sites
    2. Stop the bleeding with appropriate methods.
  5. In a patient with ongoing or recurrent bleeding in spite of treatment, consider a posterior bleeding site.
  6. In a patient with a nosebleed, obtain lab work only for specific indications (e.g., unstable patient, suspicion of a bleeding diathesis, use of anticoagulation).
  7. In a patient with a nose bleed, provide thorough aftercare instructions (e.g., how to stop a subsequent nose bleed, when to return, humidification, etc.)

General Overview

  • Most (90%) anterior bleed from Kiesselbach's plexus/Little's Area (internal/external carotid)
  • Posterior bleeds from posterolateral branches of sphenopalatine artery


  • Local trauma (Picking, foreign body, infection, allergic rhinitis)
  • Environmental (Dry)
  • Iatrogenic (NG tube)
  • Medicine (Topical steroids, antihistamines, anticoagulants)
  • Cocaine
  • Coagulopathies (platelet disorders, vW disease, hemophilia)
  • Vascular abnormalities (hereditary hemorrhagic telangiectasia [Osler-Weber-Rendu], carotid artery aneurysm)
  • Neoplasm (nasal neoplasm)

Note: Hypertension controversial


  • Trauma (r/o fracture)
  • Bleeding history (including previous epistaxis and management)
  • Medication (anticoagulants, nasal sprays/medication), Drugs (cocaine)
  • Red flags (neopastic)
    • Headache, facial pain/swelling, nasal blockage, rhinorrhea, anosmia, otalgia, loose teeth



  • Comfort in calm, quiet area to decrease anxiety
  • Position sitting forward, mouth open
  • Pressure by pinching (soft cartilaginous) anterior nose for 15-20mins (nasal ala against septum)
    • Consider ice pack to nape of neck for reflex vasoconstriction (weak evidence - expert opinion)
  • If stabilized, consider topical antiseptic ointment up to two weeks


  1. ABC, Vitals
    • Consider definitive airway, fluid resuscitation
    • Consider labs if unstable or suspect coagulopathy: CBC, INR, Blood type, cross match, consider LFT/creat
    • Consider wearing gown, gloves, mask, face shield
  2. Suction (Blow nose to remove clots or use angled Frazier 10-12F suction)
  3. Vasoconstriction
    • Topical or soaked cotton vasoconstrictors x 5-10 mins (eg. lidocaine, phenylephrine, epinephrine, cocaine, oxymetazoline)
    • Consider Tranexamic acid through atomizer and 15 minutes of external compression
  4. Cautery if bleeding source visible by nasal speculum
    • Suction and dry prior
    • Silver nitrate until gray precipitate
      • Only cauterize one side of septum (if both sides cauterized - risk of perforation)
    • Electrocautery usually done by ENT after local anesthesia
  5. Packing
    • Anterior packing (traditional vaseline gauze, compressed sponge/tampon, balloon, absorbable materials)
      • Admission/ENT consult if bilateral packing needed
    • Posterior packing (posterior source suggested in failure to visualize anterior source, bleeding from both nares, and blood in posterior pharynx)
      1. Analgesia
      2. Double balloon catheters or foley with 30mL balloon
      3. Admission to monitor for hypoxia
    • Leave packing 1-3 days prior to removal, can consider prophylactic antistaphylococcal antbiotics to prevent Toxic Shock Syndrome
      • Consider F/U ENT 48-72h
  6. Consider coagulopathy
  7. Refer to ENT/surgery for endoscopic ligation/embolization in severe cases

Prevention of re-bleeding

  • Avoid activities
    • Blowing/picking nose
    • Open mouth when sneezing
    • Heavy lifting/strenuous exercise
    • Drinking alcohol/hot drinks
    • Stop smoking/alcohol/cocaine
  • Nose care
    • Humidifier
    • Petroleum jelly (Vaseline) gently applied by Q-tip TID x 10d for dryness
    • Consider (low evidence) topical antibacterial (mupirocin) or bacteriostatic (bacitracin) ointment
    • Direct nasal sprays away from septum
  • Consider holding aspirin/antiplatelets x 6 days, NSAIDs x 3 days