HNY Policy and Pathway Repository - York

Bleeding from nose (unilateral or bilateral), caused by mechanical local trauma, or by possible other underlying systemic reasons.

• Prolonged (>20 minutes) and/or severe acute bleeding with no response to usual measures, such as local pressure and cooling
• Discharge of large or multiple clots
• Sickness with or without haematemesis
• Systemic / cardio-vascular compromise
• Signs for a possible underlying clotting problem or vasculitis
• Long standing intermittent bloody discharge for no apparent reason: adults – suspect malignancy, children or other potentially vulnerable patients – suspect foreign body.
• Unusual presentation in children under the age of two years

General Points

• Epistaxis is a common problem in children and, sometimes, adults
• The majority of cases can be managed in primary care
• If epistaxis is persistent regard it as a symptom – not a diagnosis, so, consider the possible reasons
   

Management

• Major acute bleedings would be an unusual presentation in a General Practice setting
• Establish possible reasons, timelines and measures attempted so far
• If bleeding during assessment encourage local pressure and leaning forward (avoid swallowing of blood). Establish if unilateral or bilateral bleeding
• Consider occupational history and possible related risks in adults including smoking history and possible recreational drug history
• Ask about use of over-the-counter aspirin and other NSAIDs; other medication
   
• Examination: general impression of patient, inspect nasal septum (for crusts, clots, haematoma, inflammation or other lesions / perforation / foreign bodies) and function of nose. Any other bruising or concerns (frequent bleeds from gums when brushing teeth etc)?
   
• Consider investigations such as FBC, clotting screen, auto-immune screen if unusual history or particular circumstances
• In situations with a history of recurrent minor bleeds in low-risk patients give reassurance and advice (e.g. on avoiding trauma or strain – don’t pick nose or blow nose). Petroleum jelly can be helpful to control recurrent minor bleeds.
• If nasal dryness with crusts is a problem encourage steam inhalations, nasal douches, saline sprays etc. (all available over the counter and inexpensive)
• Consider nasal cautery with silver nitrate if the history and examination suggest an anterior bleeding point. Do not cauterise both sides at the same time (risk of perforation)!
• If you don't offer cautery at the practice but feel the patient may benefit from this, please speak to the on-call SHO for an appointment at the primary care clinic (often within a week). Don't attempt cautery in children under the age of six years
• Weigh up and discuss possible risks / benefits of anticoagulants and antiplatelets if it causes major problems with recurrent epistaxis
• Locally applied Naseptin® or Bactroban® are not routinely recommended - evidence for benefit from topical therapy is very poor.
• Naseptin® could be considered in low risk patients with recurrent bleeding AND evidence of local inflammation but patients should be counselled on poor evidence risks of topically applied antibacterial agents so that they can make an informed decision NOT to have treatment if they so wish.

• Bactroban® (mupirocin) use is already driving up resistance rates in most localities and so this should definitely be reserved for patients who cannot use Naseptin® due to peanut allergy/soy allergy.
• Reassure patients that nosebleeds are usually not a sign of hypertension (check BP though). Many children experience phases of intermittent minor nose-bleeds, which can be a nuisance, but often resolve without any need for specialist management
• Educate about management of acute epistaxis and advise to call 999 in case of prolonged or major bleeds

Indications for referral

• Acute severe +/- prolonged bleed: consider an ambulance
• Recurrent medium to minor bleeds: consider a referral to the ENT primary care clinic by phone via the on-call SHO for a review and possible cautery
• More complex or persistent cases may need to be seen in the main ENT clinic, but consider Choose & Book advice (or advice from the on-call Registrar) first
   

Information to include in referral letter

• Duration and possible patterns
• Measures attempted so far (including nasal cautery)
• Occupational history and possible risk factors in adults (smoking, sniffing etc)
• Investigations so far (if any)
• Current medications (including possible over the counter medication)
• Blood pressure measurement
   

Investigations prior to referral

• Possible blood tests (FBC, clotting screen)

Patient information leaflets/ PDAs

http://www.nhs.uk/conditions/nosebleed/Pages/Introduction.aspx
 

References

• NICE Feb 2015 https://cks.nice.org.uk/epistaxis-nosebleeds 
• Leong SC, Roe RJ, Karkanevatos A. No frills management of epistaxis. Emerg Med J. 2005;22(7):470-2