Managing nosebleeds

Epistaxes (nosebleeds) are a fairly common presentation in the emergency department, and a working knowledge of the principles of management is important for junior doctors. Most cases resolve spontaneously, but patients who present at emergency departments need reassurance and prompt structured care. We also consider more specialist care.

Most epistaxis is idiopathic, but there are recognised causes (box). In nine cases out of ten epistaxes occur in the Kiesselbach's plexus, at the anterior portion of the septum known as Little's area (fig 1). Little's area is an anastomotic arterial plexus that involves all five arteries that supply the septum—the anterior ethmoidal and posterior ethmoidal arteries of the internal carotid artery and the greater palantine, sphenopalatine, and superior labial arteries of the external carotid artery.

Scenario 1—A 4 year old boy presents to his general practitioner with his anxious mother after he had a nosebleed that morning. Trauma from nose picking is a common cause of bleeding in this age group, but in many children no obvious cause is found. A detailed history may show a tendency for prolonged bleeding and may raise suspicion of a clotting disorder. In any scenario it is worth asking specifically which nostril began bleeding first. Bilateral bleeding is uncommon.