Epistaxis and major nasal bleeding

11 min read Last updated April 8, 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&E, LFT, coagulation, fibrinogen, group & 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
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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