Nose bleeds (epistaxis)

• Usually from septum (central divider) close to tip of nose
• Can be from back of nose, usually in older people — may be more severe, harder to control

Check

• Airway — look in back of mouth for blood clot, clear if need be

• If person taking warfarin — check POC Test — INR
• If person having frequent, recurrent or heavy nosebleeds — check POC Test — Hb

Do

Nose bleed leading to shock

• Sit person up — leaning forward, ask person to spit out any clot in mouth
• Put in IV cannula, largest as possible — medical consult
  
• Run normal saline 10–20mL/kg — see Injuries — bleeding
• Reassess for more fluids
• Ask person to gently blow their nose to remove any clots
• Give tranexamic acid 500mg (5mL) via nasal atomiser to affected nostril prior to insertion of packing

• Pinch fleshy lower part of nose (just below upper bony part) closing the nostrils together — must be uncomfortably tight to work properly. Person can often do this themself — Figure 2.24
• Hold for 15 minutes by the clock — if pressure released at any time — counting must restart
• Check for ongoing bleeding. Repeat pinching if needed and check that pinch technique is good
• Ask person to gently spit out any blood that trickles down back of throat
• When bleeding stops tell person not to sniff or blow nose for rest of day

If bleeding continues after more than 30 minutes of pinching

• Medical consult
• Ask person to gently blow their nose to remove any clots 
• Apply pressure from inside by putting folded swab or ribbon gauze soaked in lidocaine (lignocaine) 1% + adrenaline (epinephrine) 1:100,000 in nostril/s
• Hold for 10 minutes THEN remove packs and quickly look for bleeding site — need good light and good head position
• If bleeding site can be seen — can ‘burn’ with silver nitrate stick. Safe if
• Done on medical advice and confident about doing procedure
• Only 1 side of septum is done
• AND no known or suspected bleeding disorder

If bleeding still continues

• Put in anterior nasal pack. If person anxious — consider giving antiemetic and sedation first
• Merocel OR RapidRhino prepared nasal packing
• OR use gauze nasal packing if above not available
• After packing, check in throat for blood still trickling down from nose
• Medical consult to send to hospital
• Not urgent if bleeding stopped and/or haemodynamically stable
• If the pack is going to be in for a long time (transfer delayed over 12 hours) — Give amoxicillin oral — adult 500mg, child 15mg/kg/dose up to 500mg — doses — 3 times a day (tds)
• If allergy to penicillin — medical consult

If bleeding still continues despite anterior packing

• Urgent medical consult — see Early recognition of sepsis
• Anterior pack may be misplaced — check placement repack
• Bleeding may be from back of nose — put in posterior packing
• Posterior RapidRhino preferred if available
• Balloon catheter +/- anterior gauze packing if RapidRhino not available
• Medical consult — consider packing other nostril, deflate initial packing prior to insertion, inflate both packs simultaneously

Further management

• If bleeding site burnt — tell person to put oily cream (eg antiseptic cream, Vaseline) in nostril 2–3 times a day and gently rub outside of nose to spread it around to stop large scab and lessen the risk of another nose bleed
• Give first aid information and simple steps to stop or manage nose bleeds
• To remove Merocel or RapidRhino pack — see Nasal packing

In child

• Usually local trauma or inflammation in anterior nose and settles with pinching. Often scab (crusting) in nose removed (picked, knocked, lifted off)
• Foreign bodies in nose may cause bleeding or discharge of pus
• May need urgent referral to ENT specialist for removal
• If bleeding heavy — review in 1 day, POC Test — Hb
• If frequent nose bleeds, easy bruising, other bleeding episodes — medical consult to check FBC and clotting studies and consider referral to ENT specialist