Nosebleed (Epistaxis) Management: Correct First Aid at Home and ENT Treatment

The nasal mucosa is one of the most richly vascularised structures in the head and neck — to humidify and warm inspired air. This rich blood supply also carries bleeding risk.

On the antero-inferior septum, four arteries (anterior ethmoidal, posterior ethmoidal, superior labial, greater palatine) anastomose into Kiesselbach's plexus (Little's area). 90% of adult and nearly all paediatric epistaxis arises here. The mucosa is thin, vessels superficial, vulnerable to digital or dry-air trauma.

Posterior bleeds usually originate from the posterior septal branch of the sphenopalatine artery or from the turbinates. Blood pours toward the mouth and throat rather than the nostrils — harder to localise and the patient may swallow it.

In older patients, vessel-wall sclerosis (atherosclerosis) and hypertension cause most cases; anticoagulant/antiplatelet drugs (warfarin, DOACs, aspirin, clopidogrel) increase both frequency and severity. Related service: our general ENT services.

Anterior bleeding: blood mainly emerges from the nostrils. The patient can usually identify the affected side. Anterior rhinoscopy shows an active bleed or clot. It stops easily with correct pressure.

Posterior bleeding: blood flows directly into the mouth and throat; significant blood is spit out or swallowed. Little or none through the nostrils. Swallowed blood may cause nausea or coffee-ground vomiting. Pressure does not stop it; no anterior bleeding point.

Risk factors favouring posterior bleed: elderly (>60), uncontrolled hypertension, anticoagulant/antiplatelet use, poorly controlled diabetes, ongoing chemotherapy, history of major bleed, prior septal surgery.

Further diagnosis — after clearing anterior blood, flexible nasopharyngoscopy assesses the posterior nose; posterior pack or balloon may be required.

1. Stay calm. Panic raises blood pressure; take slow deep breaths.

2. Sit upright, lean head slightly forward. NEVER tilt back — that sends blood down the throat into the stomach; nausea/vomiting and aspiration follow.

3. Pinch the soft cartilaginous part of the nose (NOT the bony bridge) firmly between thumb and forefinger. Breathe through the mouth.

4. Maintain UNINTERRUPTED pressure for at least 10-15 minutes. Releasing to check prolongs bleeding. Use a watch or timer — the time feels much longer than it is.

5. Apply a cold compress (ice pack wrapped in towel) on the nasal bridge or cheek — reflex vasoconstriction helps.

6. If available, oxymetazoline (Afrin, Otrivin) 2 sprays into each nostril; or soak cotton and place into the bleeding side. The vasoconstrictor accelerates haemostasis.

7. After 15 minutes, release pressure slowly. If bleeding has stopped, do not blow the nose, bend over, lift heavy items or take hot showers for 6-12 hours.

8. If bleeding restarts, repeat pressure for another 15 minutes.

9. Go to ER if: bleeding does not stop after 20-30 minutes of correct pressure, large mouthfuls of blood, frequent recurrence over a month, anticoagulant therapy, dizziness/weakness/palpitations, trauma-related bleeding, periorbital bruising or vision change. More detail: septum deviation page.

Patient stabilisation: vital signs, haemodynamic status, blood pressure control (hypertensive urgency sustains bleeding). Haemoglobin/haematocrit, coagulation panel (PT/INR, aPTT), anticoagulant levels, platelet count. In severe cases, IV access and fluid resuscitation, blood products if needed.

Anticoagulation management: temporary hold until bleeding stops — for warfarin, vitamin K and possibly PCC or FFP; for DOACs, specific reversal agents (idarucizumab for dabigatran; andexanet alfa for Xa inhibitors). Decisions in collaboration with cardiology.

Anterior bleed localisation: topical decongestant + anaesthetic (lidocaine + adrenaline) followed by speculum and endoscopy.

Chemical cautery: silver nitrate stick applied to the bleeding point for 5-10 seconds; avoid spreading and bilateral simultaneous application (perforation risk).

Electrocautery: bipolar cautery is safer (more controlled tissue damage). Effective for anterior septal bleeds.

Anterior nasal pack: if cautery fails, a non-absorbable pack (Merocel, Rapid Rhino — balloon-style) is placed; left 24-48 hours; prophylactic antibiotic (toxic shock risk).

Posterior bleed: posterior balloon (Foley catheter or double-balloon posterior pack) inserted. The patient is admitted — apnoea risk (vagal reflex), cardiac side effects, hypoxia monitoring is essential.

Endoscopic sphenopalatine artery ligation (SPA-L): when posterior balloon fails or is poorly tolerated, endoscopic clipping or bipolar coagulation. Success rate >95%. Safer than embolisation and shortens hospitalisation.

Local causes: dry mucosa (winter, AC, heating), digital trauma (especially children), allergic rhinitis, chronic sinusitis, septal deviation, septal perforation, mis-applied intranasal corticosteroid spray (toward the septum), cocaine or intranasal drug use, tumours (juvenile nasopharyngeal angiofibroma in adolescent boys, squamous cell carcinoma in elderly — unilateral persistent bleeding is a warning sign).

Systemic causes: hypertension, anticoagulant/antiplatelet, coagulopathy (von Willebrand disease, haemophilia, thrombocytopenia), liver failure, renal failure, alcoholism, chemotherapy, Hereditary Haemorrhagic Telangiectasia (HHT — Osler-Weber-Rendu syndrome).

Prevention: humidify (especially winter, AC environments), saline spray 2-4 times daily, thin layer of petroleum jelly or saline gel inside the nostrils, avoid digital trauma (educate children), good blood pressure control, monitor anticoagulant level (INR target range), treat allergic rhinitis, teach correct INCS spray technique (toward the lateral wall).

HHT (hereditary haemorrhagic telangiectasia): autosomal dominant telangiectasia syndrome. Recurrent epistaxis (often starting in adolescence), GI bleeding, mucocutaneous telangiectasia, pulmonary and cerebral AVMs. Genetic counselling if suspected. Treatment: vascular embolisation, laser (Nd:YAG, KTP), septodermoplasty, last resort Young's procedure (nostril closure). We share patient experiences on our Istanbul ENT services.