Red Flag Symptoms: Epistaxis

Establish the location and extent of bleeding to guide investigations.

Epistaxis may follow triggers such as nosebleeding or sneezing
Epistaxis may follow triggers such as nosebleeding or sneezing

Epistaxis can range from a mild trickle to life-threatening haemorrhage. The commonest causes are local trauma or drying of the nasal mucosa.

Red Flag symptoms
  • Hypovolaemia or shock
  • Ongoing bleeding not stopping with direct pressure
  • Anticoagulant use
  • Multiple recurrences with no obvious cause
  • Cutaneous signs of a bleeding disorder

In dealing with this symptom, it is important to establish the site of the bleeding, including which nostril the patient thinks the blood is coming from.

Although major epistaxis may involve both nares, most patients can localise the blood flow to one side and this will help to focus the examination.

One also needs to know the duration of the bleeding as well as any potential triggers such as noseblowing, picking or sneezing. Associated symptoms may include preceding URTI, a sensation of a nasal obstruction, and nasal or facial pain.

There may be a history of previous episodes of nosebleeding. It is important to explore a history of possible bleeding diathesis, for example, easy bruising, rectal bleeding, haemoptysis, haematuria or excess bleeding when brushing teeth or trauma.

Certain conditions including cancer, HIV, liver cirrhosis and pregnancy can affect platelet function or coagulation. Also certain drugs including aspirin, NSAIDs and other antiplatelet agents such as clopidogrel, heparin or warfarin can cause this symptom.

On examination, firstly it is paramount to assess the vital signs of the patient and ensure that the patient is haemodynamically stable (check for tachycardia and hypotension). Conversely, hypertension may be the cause of epistaxis.

If there is active bleeding it may be difficult to examine the patient, and so it may be necessary to stop the bleeding first.

Anterior bleeding sites, the most common sites, may be visible on direct examination. If there is no obvious site of bleeding, but the bleed is minor then no further management may be necessary.

However, if bleeding is severe or recurrent, referral may be indicated for nasal endoscopic examination.

General examination should look for evidence of bleeding disorders, such as petechiae or purpura, perioral and oral mucosal telangiectasia as well as any intranasal masses.

Generally, further blood tests are not required. It may be worth considering an FBC, a clotting screen and LFTs if an underlying bleeding tendency is suspected.

In the primary care setting, anterior site bleeding may be controlled by pinching the nasal alae for 10 minutes while the patient sits upright. Also, cotton wool immersed in a vasoconstrictor or topical anaesthetic such as lignocaine may be inserted.

If the bleeding is more severe or posterior, the patient may need to be referred for haemorrhage control using a nasal tampon or electro-cauterisation.

  • Dr Mathukia is a GP principal in Ilford, Essex
Possible causes
  • Local trauma
  • Drying of the mucosa
  • Local infections
  • Foreign bodies
  • Systemic conditions, e.g. AIDS, sarcoidosis
  • Tumour
  • Coagulopathy
  • Osler-Weber-Rendu syndrome

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