Acute Nose Bleeds/Epistaxis Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.


This guidance refers to:

  • Patients suffering with acute nose bleeds

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Known coagulation disorder e.g. haemophilia
  • Trauma refer to A&E
  • Post nasal bleeding (i.e. bleeding profuse, both nostrils, bleeding site cannot be identified by speculum/visualisation)
  • Haemodynamically unstable


Check if the patient is taking aspirin, clopidogrel, prasugrel, warfarin or NOACs. If so, bleeding is less likely to stop easily

First aid measures:

  • Sit patient down
  • Lean patient forward (ideally over sink or table)
  • Pinch the lower part of the nose between the thumb and forefinger
  • Pinch the nose and do not release the pressure for 10-15 minutes

If the bleeding does settle with first aid measures and person haemodynamically well:

  • Naseptin QDS 10 days (or BD for 14 days if compliance an issue)
  • If neomycin, peanut or soya allergy do not use Naseptin and use mupirocin BD-TDS 5-7 days instead

If bleeding does NOT settle with first aid and appropriate expertise/facilities available:

  • Nasal cautery – use naseptin/mupirocin as above if cautery successful
  • Nasal packing – if cautery ineffective or bleeding point cannot be seen – admit patient if pack inserted in general practice

If bleeding does NOT settle with first aid and no available expertise or facilities to do nasal cautery or nasal packing:

  • Transfer to A+E


Referral Criteria

  • Red Flags should be referred to A&E via fax or phone

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation

Patient information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 08.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 08.2017
  • Publication Date: 08.2017
  • Review Date: 08.2019
  • Ref No: ENT3 - 08.2018
Any feedback or suggestions to improve this guidance should be sent to:
Only the electronic version is maintained, once printed this is no longer a controlled document


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