A quick assessment of the patient to determine stability is essential.  In an unstable patient, resuscitation takes precedence over management of epistaxis.

First aid- patient to be seated with a bowl for spitting. Pinch the nasal vestibule tightly with the thumb and index finger. Advise to breathe through mouth & spit out blood.  keep ice on nose and head; if bleeding does not settle with 5-10 minutes of continuous pressure, take the patient to a hospital.

Epistaxis could be due to local causes (e.g. trauma, foreign body, tumour, infection) or systemic causes. (e.g. bleeding disorders, hypertension) Commonly it is idiopathic.

The commonest site of nasal bleeding is Little’s area, at the anterior septum. Pinching the nasal vestibule puts pressure on this area which is the basis of first aid. Posterior bleeders are rarer but tend to be more severe.

If bleeding has abetted with pressure or if it is a mild bleed, identification and cauterisation of the bleeder can be done. Posterior bleeders may need rigid nasal endoscopy for this. Topical decongestants or adrenaline can help in the procedure. AgNO3, Bipolar diathermy or rarely heat can be used for cautery, under GA or LA.

More severe bleeders will need nasal packing with ribbon gauze or commercially available packs, either on one side or both sides, to arrest bleeding. Posterior bleeders may need a post nasal pack. The simplest form of PNS pack is a foley catheter, inserted through the bleeding nostril, inflated to match the size of the thumb, pulled anteriorly to maintain the seal in the posterior choana and secured with an umbilical clamp in that position. This has to be always combined with an anterior nasal pack.

Some centres practice primary endoscopic management of epistaxis.

Recurrent epistaxis in an adolescent boy could be due to an angiofibroma (benign tumour of post nasal space). Therefore nasal endoscopy is the priority.