One-liner#

Most nosebleeds are anterior (Kiesselbach’s plexus) and manageable with direct pressure and local measures; identify posterior bleeds and coagulopathy requiring urgent intervention.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Hemodynamic instability (hypotension, tachycardia, pallor)
• Posterior bleeding (blood draining down throat, bilateral bleeding, unable to identify source)
• Bleeding not controlled after 20-30 minutes of proper direct pressure
• Significant blood loss or signs of anemia
• Anticoagulated patient with uncontrolled bleeding
• Suspected coagulopathy (bleeding from multiple sites, easy bruising)
• Recurrent severe epistaxis
• Nasal trauma with suspected septal hematoma or fracture

Key history#

Bleeding characteristics:

• Which side? (unilateral vs bilateral—bilateral suggests posterior)
• Duration and amount of bleeding
• Blood draining down throat? (posterior bleed)
• Frequency of episodes
• What stops the bleeding? (spontaneous vs requires intervention)

Precipitating factors:

• Nose picking (most common cause)
• Dry air, low humidity
• Nasal trauma
• Recent nasal surgery or procedures
• Forceful nose blowing
• Cocaine or intranasal drug use

Medications and substances:

• Anticoagulants: warfarin, DOACs (apixaban, rivaroxaban, dabigatran)
• Antiplatelets: aspirin, clopidogrel, prasugrel
• NSAIDs
• Intranasal steroids (can cause mucosal friability)
• Cocaine, intranasal drugs

Medical history:

• Bleeding disorders: hemophilia, von Willebrand disease
• Liver disease (coagulopathy)
• Hypertension (does NOT cause epistaxis but may prolong bleeding)
• Hereditary hemorrhagic telangiectasia (HHT/Osler-Weber-Rendu)
• Prior nasal surgery
• Malignancy (nasal, sinus, hematologic)

Family history:

• Bleeding disorders
• HHT (autosomal dominant)

Focused exam#

• Vitals: BP, HR (assess for hemodynamic stability; tachycardia suggests significant blood loss)
• General: Pallor, signs of significant blood loss
• Nasal exam (after clearing clots):
  • Anterior rhinoscopy with headlight and nasal speculum
  • Identify bleeding source if possible (usually anterior septum—Kiesselbach’s plexus)
  • Look for: visible vessel, mucosal erosion, mass, septal perforation, septal hematoma
• Oropharynx: Blood draining posteriorly (suggests posterior source)
• Skin: Telangiectasias (lips, tongue, fingers—HHT), petechiae, ecchymoses
• Abdomen: Hepatosplenomegaly (liver disease, hematologic malignancy)

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Most anterior epistaxis requires no workup.

When to order labs:

• Anticoagulated patients: INR (warfarin), consider anti-Xa level (DOACs)
• Suspected coagulopathy: CBC, PT/INR, PTT
• Significant or recurrent bleeding: CBC (assess for anemia), type and screen if severe
• Liver disease: PT/INR, LFTs

When to order imaging:

• Suspected nasal/sinus mass: CT sinus
• Recurrent unilateral epistaxis without visible cause: CT or nasal endoscopy
• Suspected HHT: screening for pulmonary AVMs (CT chest with contrast), hepatic AVMs, cerebral AVMs (MRI brain)

When NOT to order workup:

• Single episode of anterior epistaxis that stops with pressure
• Clear cause identified (nose picking, dry air)
• No anticoagulation and no bleeding history

Initial management#

Step 1: First aid (patient or office)

1. Sit upright, lean slightly forward (prevents swallowing blood)
2. Pinch the soft part of the nose (not the bridge) firmly
3. Hold continuous pressure for 15-20 minutes without checking
4. Apply ice to bridge of nose (vasoconstriction)

Step 2: If bleeding continues after 20 minutes of proper pressure

1. Clear clots by having patient blow nose gently
2. Apply topical vasoconstrictor:
   • Oxymetazoline (Afrin) spray or on cotton pledget
   • Or phenylephrine-soaked cotton
3. Reapply pressure for another 10-15 minutes

Step 3: If visible bleeding vessel (anterior)

• Chemical cautery with silver nitrate stick
• Apply to vessel and surrounding area for 5-10 seconds
• Only cauterize ONE side per visit (bilateral cautery risks septal perforation)
• Apply antibiotic ointment after cautery

Step 4: If bleeding persists or source not visible

• Consider anterior nasal packing (see below)
• If posterior bleed suspected → ED for posterior packing and ENT

Anterior packing technique (if cautery fails):

• Options: absorbable packing (Gelfoam, Surgicel), non-absorbable packing (Merocel, Rapid Rhino)
• Merocel: insert dry sponge along floor of nose; hydrate with saline; expands to tamponade
• Rapid Rhino: inflate balloon per manufacturer instructions
• Leave packing in place 24-72 hours; prescribe antibiotics (amoxicillin-clavulanate) to prevent toxic shock syndrome
• Patient should follow up for packing removal

Topical tranexamic acid:

• Soak cotton pledget in tranexamic acid (500 mg/5 mL injectable solution) and pack into nostril
• Hold with pressure x 10-20 minutes
• Useful adjunct for anticoagulated patients or refractory bleeding
• Can also use crushed tranexamic acid tablet mixed with water

Anticoagulation management:

• Do NOT routinely reverse anticoagulation for epistaxis
• Control bleeding with local measures first
• Check INR if on warfarin; if supratherapeutic, may need vitamin K
• Consult with prescribing physician before holding anticoagulation
• Most patients can continue anticoagulation once bleeding controlled

Management by diagnosis#

Anterior epistaxis (uncomplicated)#

Education:

• Nosebleeds are common and usually not serious
• Most are caused by dry air, nose picking, or minor irritation
• Proper pressure technique stops most nosebleeds
• Prevention: keep nasal mucosa moist, avoid nose picking, humidify air

Treatment:

Follow-up: No routine follow-up for single episode. Return if recurrent or not controlled with home measures.

Epistaxis on anticoagulation#

Education:

• Blood thinners make nosebleeds more likely and harder to stop
• This does NOT mean you should stop your blood thinner without talking to your doctor
• Learn proper pressure technique—it works even on blood thinners
• Keep your nose moist to prevent bleeds

Management:

• Control bleeding with local measures (pressure, vasoconstrictor, cautery)
• Check INR if on warfarin
• If INR supratherapeutic (>4): consider vitamin K 2.5-5 mg PO
• If INR therapeutic and bleeding controlled: continue anticoagulation
• If recurrent despite local measures: ENT referral for cautery or intervention
• Do NOT routinely hold anticoagulation—discuss with prescribing physician

When to consider holding anticoagulation:

• Severe, uncontrolled bleeding requiring packing or transfusion
• Recurrent bleeds despite ENT intervention
• Always weigh bleeding risk vs thrombotic risk (stroke, PE, etc.)

Follow-up: 1-2 weeks to reassess; sooner if recurrent. Coordinate with anticoagulation provider.

Hereditary hemorrhagic telangiectasia (HHT)#

Recognition: Recurrent epistaxis (often since childhood), telangiectasias (lips, tongue, fingers, nasal mucosa), family history, may have iron deficiency anemia.

Curaçao criteria (≥3 = definite HHT):

1. Spontaneous, recurrent epistaxis
2. Multiple telangiectasias (lips, oral cavity, fingers, nose)
3. Visceral AVMs (pulmonary, hepatic, cerebral, GI)
4. First-degree relative with HHT

PCP role:

• Recognize pattern and refer to HHT center or ENT
• Screen for visceral AVMs (pulmonary most important—can cause stroke, brain abscess)
• Monitor for iron deficiency anemia
• Genetic counseling for family members

Screening:

• Pulmonary AVMs: contrast echocardiography (bubble study) or CT chest with contrast
• Cerebral AVMs: MRI brain
• Hepatic AVMs: if symptomatic

Follow-up: ENT for epistaxis management; HHT center if available; annual screening for AVMs.

Posterior epistaxis#

Recognition: Blood draining down throat, bilateral bleeding, unable to visualize anterior source, older patient, hypertension, anticoagulation.

PCP role:

• Recognize and refer to ED
• Attempt anterior measures while arranging transfer
• Do NOT attempt posterior packing in office (requires specialized equipment and monitoring)

Referral: ED immediately. Will require posterior packing (balloon or gauze) and ENT consultation. Often requires admission for monitoring.

Follow-up#

• Single anterior episode: No routine follow-up; return if recurrent
• Cauterized vessel: 1-2 weeks to ensure healing; apply antibiotic ointment
• On anticoagulation: 1-2 weeks; coordinate with anticoagulation provider
• Recurrent epistaxis: ENT referral for nasal endoscopy and possible intervention
• Suspected HHT: ENT referral; AVM screening

Return precautions (all patients):

• Bleeding that won’t stop after 30 minutes of proper pressure
• Feeling dizzy, lightheaded, or faint
• Blood draining down the back of your throat
• Bleeding from both nostrils
• Vomiting blood or passing dark/bloody stools

Patient instructions#

How to stop a nosebleed:

1. Sit up and lean slightly forward (don’t tilt your head back—you’ll swallow blood).
2. Pinch the soft, fleshy part of your nose firmly with your thumb and finger.
3. Hold pressure continuously for 15-20 minutes—don’t peek to check.
4. Breathe through your mouth.
5. Apply ice wrapped in a cloth to the bridge of your nose.
6. If still bleeding after 20 minutes, spray Afrin (oxymetazoline) in the bleeding nostril and hold pressure for another 15 minutes.

To prevent nosebleeds:

• Keep your nose moist: apply saline gel or a thin layer of Vaseline inside your nostrils twice daily.
• Use a humidifier, especially in winter or dry climates.
• Don’t pick your nose.
• Blow your nose gently, one nostril at a time.
• If you use nasal steroid sprays, aim away from the septum (toward the ear).

Nasal steroid spray technique to prevent epistaxis:

• Aim the spray toward the outer wall of the nose (toward the ear), NOT at the septum
• Use the opposite hand (right hand for left nostril) to angle correctly
• Don’t sniff forcefully after spraying
• If epistaxis occurs, hold the spray for a few days and restart with proper technique

Call or go to the ED if:

• Bleeding won’t stop after 30 minutes of proper pressure
• You feel dizzy or faint
• Blood is draining down the back of your throat
• You’re on blood thinners and can’t stop the bleeding

Smartphrase snippets#

Anterior epistaxis, controlled: Epistaxis from [R/L] naris, controlled with direct pressure. Anterior rhinoscopy shows [visible vessel/mucosal erosion/dry mucosa] on anterior septum. [Cauterized with silver nitrate / No cautery needed]. Discussed proper pressure technique and prevention (saline gel, humidification, avoid nose picking). Return precautions given.

Epistaxis on anticoagulation: Epistaxis in patient on [warfarin/apixaban/etc.]. Bleeding controlled with direct pressure and topical oxymetazoline. INR [X] (if applicable). No indication to hold anticoagulation at this time. Discussed prevention measures. Follow-up in 1-2 weeks; return sooner if recurrent or uncontrolled.

Recurrent epistaxis, ENT referral: Recurrent epistaxis x [X] episodes over [timeframe]. Anterior rhinoscopy shows [findings]. Given recurrence, referred to ENT for nasal endoscopy and consideration of cautery or other intervention. Continue prevention measures in the interim.

Coding/billing notes#

• Document laterality and estimated blood loss
• Document method of hemostasis (pressure, vasoconstrictor, cautery, packing)
• If cautery performed, document location and that only one side was cauterized
• Document anticoagulation status and INR if applicable
• For recurrent epistaxis, document frequency and prior interventions