Nosebleed (epistaxis)
Sit forward and pinch the soft part of the nose for 15 minutes by the clock. Most bleeds are anterior and stop with pressure or cautery.
A 68-year-old man on warfarin for a metal heart valve has had a nosebleed for 40 minutes. He is tilting his head back and swallowing blood. BP 182/100, pulse 104. INR not known. Blood is running down the back of his throat even while he pinches the front of his nose.
What first aid do you give, what do you check, and why is this bleed different from a child's nosebleed?
- Resuscitate if neededHeavy bleeding or low BP: two cannulas, CBC, clotting, INR, group and save or cross-match.
- Correct first aidSit up, lean forward, mouth open, pinch the soft part of the nose for 15 minutes without letting go.
- IceIn the mouth or on the back of the neck.
- Find the bleeding pointGood light, suction, decongestant and local anaesthetic spray. Little's area is usual.
- Visible pointSilver nitrate cautery on one side of the septum only.
- Not stoppingAnterior nasal pack (tampon or inflatable). ENT.
- Anticoagulants and BPCheck INR. Treat pain and anxiety. Don't crash the BP.
- Bleeding not stopping after 15–20 minutes of pressure
- Bleeding into the throat (posterior)
- Low BP or falling Hb
- INR high or other bleeding disorder
- Adolescent boy with recurrent one-sided bleeds and blocked nose
- Bleeding after facial trauma
- Posterior bleed
- Coagulopathy (warfarin, DOACs, liver disease, dengue, leukaemia, haemophilia)
- Juvenile nasopharyngeal angiofibroma
- Nasal or sinus tumour
- Hereditary haemorrhagic telangiectasia
- Carotid injury after trauma
| Pinch | Soft part of the nose, 15 minutes, without letting go |
| Cautery | Silver nitrate on one side of the septum only, then wait 4–6 weeks for the other |
| Anterior pack | Nasal tampon or inflatable pack, ENT review |
| Posterior bleed | Bleeding into the throat despite an anterior pack: ENT now |
| Tranexamic acid | 1 g IV or orally in heavy bleeding (topical on a pledget per local practice) |
| INR | Above the target range: discuss reversal with the senior and haematology, balancing clot risk |
Check every dose against a current drug reference and your hospital protocol.
On this page
Where do nosebleeds come from?
- Anterior (about 90%): Little's area (Kiesselbach's plexus) on the front of the septum. Common in children and young adults; dry air, nose picking, colds, allergies. Usually easy to control.
- Posterior: sphenopalatine artery branches at the back of the nose. More common in older people, hypertension, anticoagulants. Heavy, runs down the throat, needs ENT.
First aid that works
- Sit up, lean forwardNot back: blood goes into the stomach and airway.
- Pinch the soft partBelow the nasal bones, firmly, for 15 minutes without letting go to check.
- Spit out bloodDon't swallow it.
- IceIn the mouth or on the back of the neck.
- Then lookCautery or pack if still bleeding.
When first aid fails
Local anaesthetic and decongestant spray, then silver nitrate cautery for a few seconds
- Anterior nasal pack (tampon or inflatable)
- ENT review
- Posterior bleed
- ENT now
- posterior pack or balloon
- consider admission
History and examination
- Which side? Front or running down the throat? How long? How much?
- Previous nosebleeds, trauma, nose picking, recent cold.
- Anticoagulants (warfarin, DOACs), antiplatelets, NSAIDs.
- Liver disease, bleeding disorders, easy bruising, dengue in season.
- Adolescent boy with one-sided blocked nose: juvenile angiofibroma.
- Unilateral blocked nose, bloody discharge, facial numbness in an older adult: tumour.
- Pulse, BP, signs of shock, pallor.
Investigations
| Test | When |
|---|---|
| CBC | Heavy or recurrent bleeding |
| INR or clotting | On warfarin, liver disease, bleeding tendency |
| Group and save or cross-match | Heavy bleeding |
| Dengue NS1 or IgM, platelets | Fever in season |
| Imaging (CT, nasendoscopy) | Recurrent one-sided bleeding, suspected tumour |
Special situations
| Situation | What to do |
|---|---|
| On warfarin | Check INR. If very high or bleeding is heavy, discuss reversal. Metal valves: involve cardiology before reversing |
| On DOAC or antiplatelet | Usually pressure and packing; senior advice on holding the drug |
| Hypertension | Treat pain and anxiety; BP often falls when bleeding stops; don't crash it |
| Child with recurrent anterior bleeds | Antiseptic cream (for example chlorhexidine and neomycin) to Little's area for 4 weeks, avoid picking |
| Adolescent boy, one-sided bleeds and blockage | Juvenile nasopharyngeal angiofibroma: ENT and imaging; don't biopsy in clinic |
| Dengue | Platelets, haematocrit; follow dengue guidance |
Treatment
Common mistakes
- Tilting the head back.
- Pinching the bony bridge instead of the soft part.
- Letting go every minute to check.
- Cauterising both sides of the septum at once (perforation).
- Rushing to lower BP aggressively.
- Reversing warfarin in a metal valve patient without senior and cardiology advice.
- Missing a juvenile angiofibroma in a teenage boy.
Frequently asked questions
What is the first aid for a nosebleed?
Sit up, lean forward, open the mouth, and pinch the soft part of the nose firmly for 15 minutes without letting go.
When does a nosebleed need hospital?
If it doesn't stop after 15–20 minutes of pressure, is heavy, runs down the throat, or the patient is on anticoagulants or has a bleeding disorder.
Where do most nosebleeds come from?
Little's area on the front of the nasal septum.
What is a posterior nosebleed?
Bleeding from the back of the nose, often in older people, which runs down the throat and doesn't stop with pressure or an anterior pack. It needs ENT.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. What is the correct first aid for a nosebleed?
Answer: Lean forward, pinch 15 minutes. Lean forward, mouth open, firm pressure on the soft part for 15 minutes.
- Pinch the bony bridge: Wrong place.
- Lie flat: No.
- Tilt the head back: Blood is swallowed.
- Pack with cotton wool immediately: Pressure first.
2. Where do most nosebleeds come from?
Answer: Little's area. Little's area on the anterior septum (Kiesselbach's plexus).
- Nasopharynx: Rare.
- Maxillary sinus: No.
- Sphenopalatine artery: Posterior bleeds.
- Inferior turbinate: No.
3. A 15-year-old boy has recurrent one-sided nosebleeds and nasal blockage. What should be suspected?
Answer: Angiofibroma. Juvenile angiofibroma affects adolescent boys: ENT and imaging; don't biopsy in clinic.
- Nasal polyp: Rare in children, not bleeding.
- Allergic rhinitis: No.
- Common cold: No.
- Foreign body only: Less likely at this age.
4. A 14-year-old has recurrent anterior nosebleeds; a prominent bleeding vessel is seen on the anterior septum at Little’s area. How should silver nitrate cautery be performed?
Answer: One side only, periphery inwards. Anterior epistaxis (90%) arises from Kiesselbach plexus at Little’s area (anterior septum: anterior and posterior ethmoidal, sphenopalatine, greater palatine and superior labial arteries). First aid: sit forward, pinch the soft part of the nose for 10–15 minutes, ice to mouth. If a bleeding point is seen once controlled: topical anaesthetic + vasoconstrictor (lidocaine with phenylephrine/adrenaline), then silver nitrate cautery of the vessel (start around the vessel then the vessel) — only one side of the septum at a time (bilateral cautery risks septal perforation by compromising blood supply to cartilage). Afterward: chlorhexidine–neomycin cream (contains arachis/peanut oil — avoid in peanut allergy) to reduce crusting and recurrence. Packing if cautery fails. Recurrent unilateral epistaxis with obstruction in an adolescent male → consider JNA.
- Both sides at once: Cauterising both sides at once risks septal perforation.
- Heavy cautery of whole septum: Heavy cautery causes unnecessary damage.
- Onto an actively pouring bleed: Cautery fails on an actively pouring bleed.
5. A 72-year-old on warfarin for atrial fibrillation has an anterior nosebleed that stopped after first aid. INR is 2.6 (target 2–3). What is the best management of the anticoagulation?
Answer: Continue warfarin. Epistaxis in anticoagulated patients: first aid, resuscitation if needed, find and treat the bleeding point (cautery, packing). Check FBC, INR/clotting. With a therapeutic INR and controlled bleeding, anticoagulation is usually continued — stroke risk from stopping in AF outweighs a minor bleed. If INR is above range, withhold/adjust per guidelines; reversal (vitamin K, PCC; idarucizumab/andexanet for DOACs) only for life-threatening haemorrhage after discussion. Check BP (hypertension is associated but causation debated). Posterior bleeds may need posterior packing/balloon, sphenopalatine artery ligation or embolisation.
- Stop warfarin: Stopping warfarin raises stroke risk.
- Vitamin K and PCC: Reversal is not needed for a minor bleed that has stopped.
- Halve the dose: The INR is therapeutic.
6. A 15-year-old was hit on the nose in a football match and had a soft swelling on both sides of the nasal septum. He was not seen for a week and now has a collapsed nasal bridge. What mechanism caused the collapse?
Answer: Septal cartilage lost its nutrition. A septal haematoma collects between the septal cartilage and its perichondrium. Septal cartilage has no blood vessels of its own and receives its nutrients by diffusion from the perichondrium. When blood lifts the perichondrium off on both sides, the cartilage is starved and necroses within days, especially if the haematoma becomes infected. Loss of septal support gives a saddle-nose deformity.
- Displaced fracture of the nasal bones: Nasal bone fractures cause deviation, not loss of septal support.
- Osteomyelitis of the nasal bones: Osteomyelitis of the nasal bones is rare; the cartilage is the casualty.
- Resorption of the vomer bone: The vomer is bone with its own blood supply; it is not the structure lost.
- Weakening of the alar cartilages: Alar cartilages support the nostrils, not the bridge.
7. During ligation for bleeding from a tongue base tumour, a surgeon identifies the branch of the external carotid artery that arises opposite the tip of the greater horn of the hyoid and forms a short upward loop crossed superficially by the hypoglossal nerve. Which artery is this?
Answer: Lingual artery. The lingual artery arises from the front of the external carotid artery opposite the tip of the greater horn of the hyoid. It makes a characteristic upward loop, which is crossed superficially by the hypoglossal nerve, then passes deep to hyoglossus to supply the tongue. The superior thyroid artery arises lower, just below the hyoid, and runs down to the thyroid. The facial artery arises just above the lingual, often from a common linguofacial trunk, and grooves the submandibular gland.
- Facial artery: Arises just above the lingual and grooves the submandibular gland.
- Superior thyroid artery: Arises below the hyoid level and runs downwards to the thyroid.
- Ascending pharyngeal artery: Arises from the medial side near the bifurcation and runs up the pharynx.
- Occipital artery: Arises posteriorly and runs back along the posterior belly of digastric.
References and dose sources
- NICE CKS — Epistaxis (nosebleeds)
- Tranexamic acid dosing: Drugs.com: Tranexamic acid dosage (see also our tranexamic acid dose page)
- Lidocaine (lignocaine) dosing: Drugs.com: Lidocaine dosage (see also our lidocaine (lignocaine) dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.