Severe Epistaxis

Most epistaxis arises from Little's area and stops with correct first aid. Elderly anticoagulated patients can lose significant volume — treat persistent epistaxis as haemorrhage. Escalate stepwise: first aid → cautery → anterior pack → posterior…

ENT UK Epistaxis Pathway

The pathway

1 · First aid

Lean forward, pinch the soft part firmly and continuously for 10–15 min
Ice to neck/forehead
Spit, don't swallow blood

2 · Assess & resuscitate

A-E — airway, signs of shock
IV access, FBC, coagulation/INR, group & save if heavy
Elderly + anticoagulated = high risk

3 · Examine the nose

Blow clots, suction, good light
Topical lidocaine + phenylephrine
Look for a bleeding point in Little's area

4 · Cautery

Silver nitrate to visible point
One side of the septum only — never bilateral (perforation risk)

5 · Anterior pack

Rapid Rhino/nasal tampon along the floor of the nose
Admit packed anticoagulated patients
Refer ENT

6 · Anticoagulant review

Hold warfarin/DOAC if bleeding persists
Vitamin K 1–3mg IV if INR raised with bleeding
PCC only for life-threatening haemorrhage

7 · Posterior bleed

Blood in pharynx despite anterior packs
Posterior pack (Foley/dedicated) by ENT
Failure → theatre: sphenopalatine ligation or embolisation

Drugs

Drug	Dose	Route	Notes
Lidocaine 5% + phenylephrine 0.5%	Topical spray	TOP	Anaesthetises and vasoconstricts before examination/cautery.
Silver nitrate stick	75%	TOP	One side of septum only. 5–10 seconds around the bleeding point.
Vitamin K (phytomenadione)	1–3mg	IV	For bleeding with raised INR. Takes ~6 hours.
Tranexamic acid	1g TDS	PO/IV	Consider in persistent bleeding per local policy.
Naseptin cream	QDS 10 days	TOP	After control — reduces recurrence. Contains peanut oil — check allergy.

When to escalate

Haemodynamic compromise — tachycardia, hypotension, pallor,Bleeding through or around an anterior pack,Posterior bleeding (blood in the pharynx),INR >8 or major bleeding on anticoagulation — discuss haematology,Recurrent admissions — ENT outpatient work-up

Reference: ENT UK Epistaxis 2016 consensus / NICE CKS Epistaxis

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