Epistaxis (Nosebleed)
Causes, first aid, treatment and prevention — including anticoagulated patients
Epistaxis (nosebleed) is one of the most common ENT emergencies. The vast majority of cases arise from the front of the nose (anterior epistaxis) and are self-limiting, but posterior bleeds and those in anticoagulated patients require urgent medical assessment. Understanding the correct first aid technique and when to seek help can prevent serious complications.
What causes nosebleeds?
Most nosebleeds originate from Little's area (Kiesselbach's plexus) — a rich network of small blood vessels on the front of the nasal septum. This area is vulnerable to drying, crusting, nose-picking and minor trauma. Posterior bleeds arise from the sphenopalatine artery deeper in the nose and are more serious. Common precipitants include dry air, upper respiratory infections, nose-blowing, nasal steroid sprays (if used incorrectly), high blood pressure, and medications that affect clotting — including aspirin, NSAIDs, warfarin and direct oral anticoagulants (DOACs). Hereditary haemorrhagic telangiectasia (HHT) is a rarer inherited cause of recurrent epistaxis.
First aid — what to do during a nosebleed
The correct technique is critical and often not what people instinctively do. Sit upright and lean slightly forward — not backwards, as this causes blood to run down the throat. Pinch the soft part of the nose (below the bony bridge) firmly, continuously, for at least 10–15 minutes without releasing. Breathe through the mouth and spit out any blood — do not swallow it. A cold compress on the bridge of the nose may help. Avoid hot drinks, blowing the nose, or heavy exercise for 24 hours after the bleed. If bleeding has not stopped after 20 minutes of sustained pressure, seek urgent medical assessment.
Treatment options
For anterior bleeds with an identifiable bleeding point, silver nitrate cautery is the most effective first-line treatment — applied directly to Kiesselbach's plexus. Only one side of the septum should be cauterised at a time to avoid septal perforation. Tranexamic acid — either applied topically on a soaked gauze or taken orally (1g three times daily for 5–7 days) — is an antifibrinolytic drug that helps stabilise clots and is particularly useful in anticoagulated patients. Naseptin cream (chlorhexidine + neomycin) applied twice daily to Little's area for two weeks after an episode moisturises the mucosa and reduces the chance of recurrence — but must be avoided in patients with peanut allergy, as it contains arachis oil. If these measures fail, nasal packing may be required. Posterior bleeds and those not responding to first aid require urgent ENT assessment.
Managing epistaxis in patients on anticoagulants
Anticoagulated patients — including those on warfarin or DOACs — require careful assessment. For warfarin patients, the INR should be checked: if it is above 4, warfarin should be withheld and oral vitamin K (1–5 mg) given for non-urgent reversal. However, warfarin should not be stopped if the INR is within the therapeutic range without specialist advice, due to the risk of thromboembolic events. For DOACs, routine reversal is not recommended unless the bleed is life-threatening. Tranexamic acid is safe to use alongside all anticoagulants and is the preferred adjunct. Aspirin for secondary prevention of MI or stroke should not be stopped for epistaxis alone — the cardiovascular risk outweighs the benefit. Always review the medication list for avoidable causes: OTC NSAIDs and incorrectly used nasal steroid sprays. This article has been prepared following careful evaluation of NICE CKS Epistaxis (2023) and ENT UK guidelines.