Epistaxis and major nasal bleeding

11 min read Last updated April 9, 2026

Surgical approach

  • Initial measures (usually ED/ENT at bedside)
    • Sit patient forward, pinch soft part of nose, suction clots, topical vasoconstrictor (e.g. phenylephrine/xylometazoline) ± topical local anaesthetic
    • Identify anterior source (Little’s area) → chemical/electrocautery if visible and patient stable
  • Packing
    • Anterior pack (e.g. Merocel/rapid rhino balloon) if bleeding persists or source not seen
    • Posterior pack/balloon (e.g. Foley/epistaxis balloon) for suspected posterior bleed, often combined anterior + posterior packing
    • Pack removal typically after 24–72 h depending on severity/local policy, consider antibiotics if non-absorbable packing (local policy varies)
  • Operative / interventional escalation (if ongoing bleeding, recurrent after packing, or haemodynamic compromise)
    • Endoscopic control: suction + bipolar/diathermy of bleeding point
    • Endoscopic sphenopalatine artery ligation (SPAL) ± anterior ethmoidal artery ligation (less common, higher risk)
    • Septal surgery if septal source/haematoma, address trauma-related fractures if relevant
    • Interventional radiology: selective arterial embolisation (usually internal maxillary/sphenopalatine branches, sometimes facial artery)

Anaesthetic management (typical cases: packing under GA, endoscopic cautery/ligation, embolisation)

  • Type of anaesthesia
    • GA for major bleeding, posterior packing, endoscopic surgery, uncooperative patient, or aspiration risk
    • Local/topical ± sedation may be used for minor anterior cautery/packing in stable patients (avoid oversedation)
  • Airway device
    • Rapid sequence induction (RSI) commonly required due to swallowed blood/full stomach, head-up if tolerated
    • Use large-bore suction, consider second suction catheter, throat pack may be used (must be documented/removed)
    • SGA generally inappropriate in major epistaxis (poor airway protection, blood contamination)
  • Duration
    • Packing/cautery: ~15–45 min, SPAL: ~45–90 min, embolisation: ~60–120 min (variable)
  • How painful
    • Moderate: nasal packing and endoscopic work can be uncomfortable, postoperative pain usually manageable with paracetamol ± opioids, avoid NSAIDs if bleeding risk
  • Key anaesthetic goals
    • Treat as potential major haemorrhage: early IV access, bloods, crossmatch, warming, calcium, TXA where appropriate
    • Prevent aspiration: suction, RSI, cuffed ETT, consider NG/OG only after airway secured if needed
    • Haemodynamic stability and controlled BP (avoid hypertension/tachycardia that worsens bleeding)

Definition and classification

  • Epistaxis = bleeding from nasal cavity, common, usually self-limiting, can be life-threatening if posterior/major haemorrhage or in anticoagulated patients
  • Anterior (≈90%): usually Kiesselbach’s plexus (Little’s area) on anterior septum
  • Posterior: often sphenopalatine artery branches, more severe, older patients, higher admission/recurrence

Relevant anatomy (high yield)

  • Arterial supply (ECA and ICA contributions)
    • ECA: maxillary artery → sphenopalatine artery (major posterior supply), facial artery → superior labial
    • ICA: ophthalmic artery → anterior/posterior ethmoidal arteries (anterior-superior septum/lateral wall)
    • Kiesselbach’s plexus (Little’s area): anastomosis of septal branches (sphenopalatine, anterior ethmoidal, superior labial, greater palatine)
  • Venous drainage communicates with cavernous sinus (infection spread risk) and pterygoid plexus

Aetiology and risk factors

  • Local causes
    • Trauma (nose picking, facial trauma, iatrogenic: NG/NP airway), mucosal dryness, infection/inflammation, septal deviation/perforation
    • Tumour (e.g. juvenile nasopharyngeal angiofibroma), hereditary haemorrhagic telangiectasia (HHT)
  • Systemic causes
    • Hypertension (association with severity/recurrence rather than direct cause), coagulopathy (liver disease, thrombocytopenia), anticoagulants/antiplatelets (warfarin, DOACs, aspirin, clopidogrel)
    • Alcohol excess, renal failure/uraemia, pregnancy

Initial assessment and resuscitation (A–E)

  • Airway
    • Look for blood in mouth/pharynx, continuous suction, consider early intubation if ongoing heavy bleeding, reduced consciousness, or inability to protect airway
    • Avoid nasal airways/NG tubes in active bleeding or suspected basal skull fracture
  • Breathing
    • High-flow oxygen, monitor SpO2, aspiration risk is high (swallowed blood, clots)
  • Circulation
    • 2 large-bore IV cannulae, send FBC, U&amp,E, LFT, coagulation, fibrinogen, group &amp, screen/crossmatch, consider VBG/ABG and lactate
    • Fluid resuscitation with warmed crystalloids initially, early blood products if major haemorrhage, activate major haemorrhage protocol if indicated
    • Correct coagulopathy: platelets, FFP, cryoprecipitate/fibrinogen concentrate as per labs/ROTEM, give calcium during massive transfusion
    • Tranexamic acid: consider in significant bleeding (systemic 1 g IV) and/or topical (local practice), balance against thrombotic risk
  • Disability/Exposure
    • Check GCS, consider alcohol/intoxication, keep warm, quantify blood loss (often underestimated due to swallowing)

Airway strategy in major epistaxis (FRCA viva framework)

  • Key problems
    • Blood/clots obscure view, patient may be hypovolaemic, full stomach from swallowed blood
  • Preparation
    • ENT presence if possible, difficult airway trolley, videolaryngoscope ready, 2 suctions, wide-bore Yankauer + catheter suction
    • Pre-oxygenate head-up, consider apnoeic oxygenation, arterial line if unstable/ongoing bleeding
  • Induction and intubation
    • RSI with cricoid pressure (apply judiciously, release if impedes view/ventilation), choose induction agent based on haemodynamics (ketamine/etomidate often appropriate, titrated propofol if stable)
    • Paralysis: rocuronium (with sugammadex available) or suxamethonium, ensure ability to ventilate if not classic RSI
    • Cuffed oral ETT, confirm with capnography, consider cuff pressure and secure well (blood/secretions reduce adhesion)
  • If cannot intubate / cannot oxygenate (CICO)
    • Follow DAS guidelines, early declaration, scalpel-bougie cricothyrotomy

Anaesthesia for nasal packing / endoscopic haemostasis / SPAL

  • Monitoring and access
    • Standard monitoring, consider arterial line for major bleed/vasoactive infusions, large-bore IV access, warming
  • Maintenance
    • Volatile or TIVA, avoid coughing/bucking (increases venous pressure and bleeding): adequate depth, opioid, lidocaine, smooth emergence
    • Controlled hypotension sometimes requested for surgical field but avoid in hypovolaemia/anaemia, prioritise perfusion
  • Analgesia and antiemetics
    • Paracetamol ± opioid, avoid NSAIDs if ongoing bleeding risk, consider local infiltration/topical LA by surgeon
    • High PONV risk (swallowed blood): dual antiemetics (e.g. ondansetron + dexamethasone) unless contraindicated
  • Extubation strategy
    • Ensure haemostasis and suction stomach/oropharynx, remove throat pack, consider extubation fully awake with protective reflexes
    • If ongoing bleeding, posterior packs, significant aspiration risk, or major transfusion/instability: consider postoperative ventilation/ICU

Anaesthesia for embolisation (IR suite)

  • Environment and logistics
    • Check access to airway, suction, blood products, radiation precautions, limited patient access once draped
  • Technique
    • Often GA with ETT for active bleeding/uncooperative patient, sedation only if stable and airway low risk (rare in major epistaxis)
    • Anticoagulation may be used by IR (heparinised flush), clarify plan, manage BP to reduce rebleed while maintaining cerebral perfusion
  • Complications to anticipate
    • Non-target embolisation via anastomoses (ECA–ICA/ophthalmic) → stroke, facial necrosis, visual loss, post-procedure neuro checks

Haematology: reversal of anticoagulants/antiplatelets (outline)

  • Warfarin
    • Major/life-threatening bleeding: 4-factor PCC + IV vitamin K (dose per local guideline/INR), check INR response
  • DOACs
    • Hold drug, consider activated charcoal if very recent ingestion, assess renal function and last dose
    • Dabigatran: idarucizumab if life-threatening bleeding, Xa inhibitors: andexanet alfa where available/indicated or PCC per local policy
  • Antiplatelets
    • Discuss risk/benefit with ENT/haematology/cardiology, platelet transfusion may help in life-threatening bleeding (especially with irreversible agents), but evidence varies

Complications and postoperative care

  • Airway/respiratory
    • Aspiration pneumonitis, airway obstruction from clots, laryngospasm on emergence
    • Posterior packing can cause hypoxia/OSA-like obstruction, consider HDU monitoring
  • Cardiovascular
    • Hypovolaemic shock, myocardial ischaemia (older patients), arrhythmias, monitor Hb and troponin if indicated
  • Local nasal complications
    • Rebleeding, septal necrosis/perforation, sinusitis/otitis media, pressure necrosis with prolonged packing
  • Infection/toxic shock syndrome (rare)
    • Fever, hypotension, rash after packing, requires urgent review and antibiotics/supportive care

Test yourself…

You are called to ED for a 72-year-old with ongoing heavy epistaxis, hypotension and confusion. Talk through your immediate management.

Structure: A–E, resuscitate, call for help, prepare for definitive haemostasis and airway protection.

  • Call for help early: senior anaesthetist, ENT, ED resus team, consider activating major haemorrhage protocol
  • Airway: sit forward if conscious, suction, high-flow O2, assess ability to protect airway, prepare for early RSI if ongoing bleeding/low GCS
  • Breathing: monitor SpO2/EtCO2 if intubated, consider aspiration, auscultate, CXR later if aspiration suspected
  • Circulation: 2 large-bore IVs, bloods (FBC, coag, fibrinogen), crossmatch, warmed fluids, early RBC/FFP/platelets guided by MHP/ROTEM, give calcium
  • Temporising haemostasis: topical vasoconstrictor, anterior ± posterior packing by ENT/ED while resuscitating
  • Definitive plan: theatre for endoscopic control/SPAL or IR embolisation depending on availability and patient factors
Why is major epistaxis an airway problem? What are the specific anaesthetic risks?

Think: aspiration, obscured view, full stomach, haemodynamic instability, and difficult emergence.

  • Swallowed blood → full stomach → high aspiration risk, blood in pharynx can cause laryngospasm
  • Blood/clots obscure laryngoscopy and can block suction, may require two suctions and videolaryngoscopy
  • Hypovolaemia/anaemia → haemodynamic collapse at induction, careful choice/titration of induction agent and early blood
  • Posterior packs can obstruct airway post-op, risk of hypoxia and need for HDU/ICU
Describe your RSI plan for a patient with active epistaxis requiring urgent theatre.

Aim: rapid airway protection with strategies to manage blood contamination and difficult view.

  • Preparation: head-up preoxygenation, two working suctions, videolaryngoscope ready, difficult airway plan and FONA kit
  • Induction: haemodynamically appropriate agent (ketamine/etomidate or carefully titrated propofol) + rocuronium (with sugammadex available) or suxamethonium
  • Cricoid pressure: apply if trained assistant, be ready to release if it worsens view/ventilation
  • Intubation: cuffed oral ETT, confirm with capnography, secure tube, consider throat pack (document/remove)
  • Failure plan: limit attempts, suction between attempts, early second operator, consider bougie, if CICO follow DAS and perform scalpel-bougie cricothyrotomy
What are the indications for ICU/HDU after surgery for epistaxis?

Think: airway risk, physiological derangement, ongoing bleeding, and comorbidity.

  • Ongoing bleeding or high risk of rebleed, posterior packing in situ with risk of obstruction/hypoxia
  • Aspiration event, respiratory compromise, need for postoperative ventilation
  • Major transfusion, shock, significant anaemia, need for vasopressors or invasive monitoring
  • Significant comorbidity (IHD, severe COPD/OSA), frailty, or poor physiological reserve
A patient is on warfarin with INR 4.2 and has life-threatening epistaxis. How do you reverse anticoagulation?

Follow local major bleeding anticoagulation reversal guideline.

  • Give 4-factor PCC (dose per INR/weight/local protocol) + IV vitamin K
  • Send repeat INR after PCC, continue haemostatic resuscitation (fibrinogen/platelets as needed) and treat bleeding source
  • Consider TXA and involve haematology early
How does posterior nasal packing affect physiology and what complications can it cause?

Posterior packs are not benign, they can compromise airway and cardiorespiratory function.

  • Upper airway obstruction and hypoventilation, especially during sleep/sedation, may worsen OSA
  • Hypoxia/hypercapnia, need for supplemental O2 and close monitoring (often HDU)
  • Vagal responses during insertion (bradycardia), discomfort, hypertension/tachycardia increasing bleeding
  • Pressure necrosis, sinusitis/otitis media, rare toxic shock syndrome
Compare endoscopic sphenopalatine artery ligation (SPAL) and embolisation for refractory epistaxis.

Both aim to control posterior bleeding, choice depends on availability, patient factors, and recurrence/risks.

  • SPAL: surgical control under GA, avoids radiation/contrast, effective for posterior bleeds, operative risks include anaesthesia, rebleed, local injury
  • Embolisation: IR option, useful if surgical failure or high surgical risk, can be done urgently if IR available, risks include non-target embolisation (stroke, blindness), contrast nephropathy, groin complications
  • Anaesthetic implications: both often require GA with ETT due to aspiration risk, embolisation is remote-site with limited access and radiation precautions
What drugs might the ENT surgeon use topically and what are the anaesthetic implications?

Commonly vasoconstrictors and local anaesthetic, watch for cardiovascular effects and LA toxicity.

  • Topical vasoconstrictors: phenylephrine, adrenaline (with LA), xylometazoline
  • Implications: hypertension, tachyarrhythmias, myocardial ischaemia (especially elderly/IHD), communicate doses and timing
  • Local anaesthetic: lidocaine/cocaine (less common), risk of systemic toxicity—calculate maximum dose and monitor
A patient continues to bleed after anterior packing. What are the next steps and what does this suggest?

Persistent bleeding suggests posterior source or inadequate packing/coagulopathy.

  • Reassess: haemodynamic status, ongoing blood loss, airway protection, repeat A–E and labs/coagulation
  • Escalate to posterior packing (often combined anterior + posterior) and involve ENT urgently
  • Correct coagulopathy/anticoagulation, consider TXA
  • Plan definitive control: endoscopic cautery/SPAL or embolisation
What are the key points for safe use of a throat pack in epistaxis surgery?

Throat packs can reduce blood ingestion but introduce a serious retained foreign body risk.

  • Insert only when indicated, document clearly (whiteboard, anaesthetic chart) and include in swab count
  • Ensure a clear plan for removal: verbal confirmation with surgeon before extubation
  • Suction oropharynx after removal, consider OG suction if large swallowed blood volume (after airway secured)
Outline your approach to the anaesthetic management of a patient with major epistaxis requiring urgent surgical control.

A structured answer scores well: assessment/resuscitation, airway plan, maintenance, emergence, and postoperative destination.

  • Resuscitation first: A–E, IV access, bloods/crossmatch, early blood products, correct coagulopathy, warming, TXA as appropriate
  • Airway: high aspiration risk → RSI with cuffed oral ETT, two suctions, videolaryngoscope, difficult airway and CICO plan
  • Intra-op: maintain anaesthesia, avoid hypertension/coughing, consider arterial line, communicate with ENT about vasoconstrictors and blood loss
  • Emergence: suction, remove throat pack, antiemetics, extubate awake, consider ICU if posterior pack/ongoing bleeding/aspiration/instability
Discuss the causes and management of peri-induction hypotension in a patient with epistaxis.

Link physiology (hypovolaemia/anaemia) with anaesthetic drug effects and ongoing bleeding.

  • Causes: hypovolaemia from blood loss (often hidden), vasodilation from induction agents, myocardial ischaemia/arrhythmia, sepsis (rare), vagal response to packing
  • Management: stop/limit anaesthetic dose, fluid/blood bolus, vasopressors (metaraminol/phenylephrine/noradrenaline infusion), treat arrhythmia, correct hypocalcaemia during transfusion
  • Prevention: early resuscitation, arterial line, choose haemodynamically stable induction agent, have blood in theatre before induction if possible
A patient with epistaxis is taking apixaban. What information do you need and what are your options to manage bleeding perioperatively?

FRCA expects a pragmatic approach: history, renal function, timing, severity, and local reversal policy.

  • Need: last dose time, dose, renal function, indication (AF/VTE), other antiplatelets, bleeding severity, baseline coagulation (though routine tests may be insensitive)
  • Options: hold drug, local haemostatic measures, consider TXA, for life-threatening bleeding consider andexanet alfa (if available/criteria met) or PCC per local guideline, involve haematology
  • Balance thrombosis risk vs bleeding, plan restart with ENT/haematology once haemostasis achieved

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