Nosebleeds (epistaxis): how to stop them and prevent recurrence

What a nosebleed actually is

A nosebleed (epistaxis) is one of the most common acute presentations in Australian general practice and emergency departments. Around 60% of Australians experience at least one episode during their lifetime, and roughly 6% will seek medical care at some point. The vast majority — approximately 90% — are anterior bleeds from the nasal septum, are visible and accessible, and respond to basic first-aid within 15 minutes.

The nose receives a rich blood supply from five arterial branches that converge at Kiesselbach’s plexus — also called Little’s area — on the anteroinferior nasal septum. This convergence makes it vulnerable to bleeding from even minor mucosal trauma, dryness, or inflammation. The remaining 10% of bleeds arise posteriorly, usually from the sphenopalatine artery territory. Posterior bleeds are more common in older adults, produce higher blood volumes, may be swallowed rather than draining anteriorly (sometimes presenting as nausea or altered bowel motions from haematin in the stool), and more often require hospitalisation and specialist assessment.

Hypertension is frequently associated with epistaxis but current evidence, including the 2020 AAO-HNS guideline, places it as an aggravating rather than primary cause — the blood pressure elevation seen during a bleed is often a stress response to the event itself rather than its aetiology.

A. Core clinical — the AU general-practice framework

Anatomy and classification

Anterior epistaxis (~90%): bleeding from Kiesselbach’s plexus on the anteroinferior nasal septum; self-limited in most cases; visible on inspection with a headlight and nasal speculum.

Posterior epistaxis (~10%): bleeding from the sphenopalatine artery or posterior ethmoidal branches; more common in older adults; higher volume; blood may be swallowed; usually requires specialist management and hospital admission.

Causes

Local causes include nasal trauma (nose-picking is the commonest cause in children; blunt facial injury in adults), mucosal dryness from low-humidity environments, air-conditioning or continuous oxygen therapy, allergic or infectious rhinitis, sinusitis, septal perforation from intranasal cocaine or methamphetamine use, and less commonly nasal tumour. Two tumour diagnoses that must not be missed are nasopharyngeal carcinoma in adults of Asian background and juvenile angiofibroma in adolescent males.

Systemic causes include anticoagulants and antiplatelets — warfarin, apixaban, rivaroxaban, dabigatran, aspirin, clopidogrel, ticagrelor, prasugrel — and inherited or acquired coagulopathy: von Willebrand disease (the most common inherited bleeding disorder), haemophilia A or B, liver disease, DIC, and thrombocytopenia from ITP, drug effect, or haematological malignancy. Australian Medicines Handbook (AMH) provides a full reference for anticoagulant and antiplatelet drug interactions affecting bleeding risk.

Hereditary haemorrhagic telangiectasia (HHT, Osler-Weber-Rendu syndrome) is a specific autosomal dominant condition causing recurrent epistaxis from nasal telangiectasia plus AVMs in the lung, brain, and GI tract — it requires specialist referral.

First-line management — the universal first step

Per Therapeutic Guidelines (eTG), the following applies to virtually every nosebleed presentation:

1. Sit upright; lean forward — prevents aspiration or swallowing of blood, which provokes nausea and vomiting, and keeps the airway clear.
2. Pinch the soft alae of the nose firmly between thumb and forefinger, continuously, for 10–15 minutes without releasing to check. Squeeze the soft fleshy part — not the bony bridge, which achieves nothing.
3. Breathe through the mouth; spit out blood — do not swallow.
4. Do not tilt the head back — this sends blood into the nasopharynx.

Most anterior bleeds settle with this manoeuvre. Patients commonly underestimate elapsed time; encourage them to time it on a clock. A bleed that stops within 15 minutes can almost always be managed conservatively; one that does not after two solid attempts warrants GP assessment the same day.

GP escalation pathway

Topical agents:

• Oxymetazoline 0.05% (Drixine, Vicks Sinex) — vasoconstrictor; multiple sprays into the bleeding nostril; fast-acting; available over the counter. AMH
• Co-phenylcaine (lignocaine 5% + phenylephrine 0.5%) — combined anaesthetic and vasoconstrictor spray; very useful for GP assessment and minor procedures in the consulting room.
• Topical tranexamic acid — 500 mg/5 mL injection solution applied to a cotton-tip or pledget; several randomised controlled trials support its use as an adjunct, reducing bleeding time and rebleed rates. eTG

Visualise and cauterise: After topical preparation, anterior rhinoscopy with a headlight and nasal speculum can identify the bleeding vessel in Little’s area. Silver nitrate cautery (75% stick, applied 3–5 seconds to the identified point) is effective for visible bleeding. Avoid cauterising both sides of the septum simultaneously — bilateral septal cautery significantly increases the risk of septal perforation.

Anterior nasal packing: If cautery is not feasible or fails:

• Rapid Rhino (carboxymethylcellulose hydrogel) — inflate with water; preferred because it is easier and less traumatic to remove than earlier gauze packs.
• Merocel (polyvinyl acetate foam sponge) — expands on contact with blood or saline.
• Packs are left in for 24–72 hours. The AAO-HNS 2020 guideline does not recommend routine prophylactic antibiotics for short-duration anterior packing in immunocompetent patients — toxic shock syndrome risk is minimal.

Posterior bleeding: Suspected posterior bleeding (heavy volume, blood visible in the posterior pharynx, bilateral nasal packing ineffective) requires same-day hospital assessment. Management involves a posterior tamponade balloon, a Foley catheter inflated in the nasopharynx, or ENT-guided endoscopic vessel ligation or arterial embolisation.

Selective investigation

Not every epistaxis episode needs investigation. Consider investigation selectively for:

• Heavy or recurrent bleeding without an identifiable local cause
• Young patient or positive family history — von Willebrand disease screen (vWF antigen, vWF ristocetin cofactor activity, Factor VIII level)
• Anticoagulant management — check INR if on warfarin; contact the prescriber before altering the dose
• Suspected haematological cause — FBC, coagulation panel (PT, APTT, fibrinogen), liver function tests
• HHT suspicion — recurrent epistaxis plus telangiectasia on lips, tongue, or fingertips plus a family history; ≥3 of 4 Curaçao criteria is diagnostic. Refer to Australasian Society of Thrombosis and Haemostasis (ASTH) and haematology

B. Evidence appraisal — what the evidence shows

Topical tranexamic acid

Multiple randomised controlled trials and systematic reviews support topical tranexamic acid as an effective adjunct for acute epistaxis management. Topical application — via soaked pledget held in the nostril for 10 minutes — reduces bleeding time and rebleed rates without the systemic absorption concerns of intravenous use. Oral tranexamic acid (500 mg–1 g three times daily for 5–7 days) is a reasonable adjunct for moderate or recurrent bleeds. eTG includes tranexamic acid as a recommended adjunct at both topical and oral routes.

Silver nitrate cautery

Chemical cautery with silver nitrate is effective and widely used when the bleeding point in Little’s area is identifiable under direct visualisation. The critical caveat is to avoid bilateral simultaneous septal cautery — treating the same area on both sides of the septum in the same sitting significantly increases the risk of septal perforation and should be reserved for separate sessions at minimum.

Routine antibiotics with packing — not indicated

The AAO-HNS 2020 guideline reviewed the evidence comprehensively and found no support for routine prophylactic antibiotics accompanying anterior nasal packs of standard duration in immunocompetent patients. Reserve antibiotics for prolonged packing (over 48–72 hours), immunocompromised patients, or clear signs of secondary infection — this avoids unnecessary antibiotic exposure and resistance selection.

Stopping anticoagulation — generally avoid

The ASTH and eTG both advise that anticoagulation should generally be continued for self-limited or mild epistaxis. The thrombotic risks of cessation — stroke in AF, pulmonary embolism, prosthetic valve thrombosis — typically outweigh the haemorrhagic risk from a controlled nosebleed. Where a bleed is heavy or persistent, decision-making requires case-by-case risk-benefit discussion with the prescriber or a haematologist, not unilateral cessation.

Acute blood pressure lowering — modest priority

Although blood pressure is commonly elevated during an active nosebleed, attempting aggressive acute lowering delays haemostasis and carries hypotension risk. Local haemostasis is the first priority; once the bleed is controlled, a target blood pressure of ≤160/100 mmHg is reasonable. Long-term blood pressure management is the appropriate chronic intervention — not the initial acute focus.

C. Prevention and ongoing mucosal care

Once acute bleeding has been controlled, the goal shifts to reducing recurrence.

Moisturise the nasal mucosa:

• Saline nasal spray (FESS, Flo) — several times daily, especially in air-conditioned or heated environments. HealthDirect recommends this as a simple and effective preventive step.
• Petroleum jelly or paw paw ointment — a small amount applied to the inside of each nostril twice daily for 1–2 weeks after a bleed helps repair the mucosal barrier at the site of the previous bleed.
• Bedside humidifier — particularly valuable in winter when indoor heating drives down relative humidity; reduces overnight mucosal desiccation.

Treat allergic rhinitis: Allergic rhinitis is a major contributor to recurrent anterior epistaxis — mucosal inflammation and oedema make the fragile vessels of Little’s area more prone to bleeding. An intranasal corticosteroid spray (budesonide, fluticasone, mometasone) is effective but technique is critical: direct the nozzle toward the outer wall of the nasal passage — away from the septum — to prevent mucosal contact. NPS MedicineWise provides technique guides for patients. Antihistamines (cetirizine, loratadine) are useful adjuncts for symptom management.

Behavioural measures: Avoid nose-picking — the most preventable trigger of recurrent anterior epistaxis. Avoid forceful nose-blowing for several days after a bleed. Sneeze with the mouth open to reduce intranasal pressure. Avoid Valsalva manoeuvres. Avoid NSAIDs if high-dose regular use is contributing.

Review anticoagulant selection: Recurrent epistaxis in a patient on anticoagulation warrants a review of choice and dose — in selected cases, switching to a different agent or lower dose may reduce bleeding frequency. This decision requires specialist input. Never alter anticoagulation unilaterally. ASTH

D. Australian operations

The RACGP supports a tiered management approach for epistaxis in general practice: first-aid education as the primary intervention, GP-level assessment and escalation for persistent bleeds, and ENT or emergency referral for posterior bleeds or red flags.

MBS item numbers (via MBS Online):

• Item 23 — standard Level B GP consultation
• Items 36 / 44 — longer Level C/D consultations for complex cases
• Item 41653 — silver nitrate cautery for epistaxis
• Item 41659 — anterior nasal packing for epistaxis
• Items 41671 / 41672 — posterior nasal packing (typically specialist)
• GPCCMP items 965 / 967 — chronic recurrent epistaxis or HHT under a complex care plan (replaced items 721/723/732 from 1 July 2025)
• Item 715 — ATSI Health Assessment when epistaxis is part of a comprehensive assessment

Medications and PBS access:

• Oxymetazoline (Drixine, Vicks Sinex) — over-the-counter; first-line vasoconstrictor; no prescription required. AMH
• Co-phenylcaine — clinic stock; not PBS-listed individually; GP consumable.
• Tranexamic acid oral 500 mg — available on the PBS General Schedule; GP prescribing.
• Intranasal corticosteroids — over the counter or PBS prescription; central to managing underlying allergic rhinitis.
• Anticoagulant reversal — idarucizumab (Praxbind, PBS) for dabigatran reversal; andexanet alfa for factor Xa inhibitors (limited AU availability); Prothrombinex-VF plus FFP for urgent warfarin reversal; vitamin K oral/IV for non-urgent warfarin reversal.

Australian patient and clinician resources:

• HealthDirect — Nosebleeds
• Better Health Channel — nose and throat conditions
• Australian HHT Association — patient and clinician resources for hereditary haemorrhagic telangiectasia
• ASOHNS — consumer and clinician resources on ENT conditions

E. Special populations

Children: Recurrent anterior epistaxis in children is extremely common and is almost always benign — typically from nose-picking or mucosal dryness at Little’s area. Reassurance, saline spray, petroleum jelly, and treating allergic rhinitis are appropriate for typical presentations. Investigate if bleeds are very heavy, occur more than once a week, are associated with bruising elsewhere, or there is a family history of a bleeding disorder — von Willebrand disease should be considered and is the most common inherited coagulopathy. A unilateral foul-smelling nasal discharge with bleeding in a young child suggests a nasal foreign body until proven otherwise — do not attempt removal without appropriate equipment and lighting.

Adolescent males: Unilateral recurrent epistaxis in an adolescent male, particularly with a visible nasal mass or nasal obstruction, raises concern for juvenile angiofibroma — a highly vascular benign tumour arising in the nasopharynx. This must never be biopsied in the clinic; the risk of uncontrolled haemorrhage is serious. Refer urgently to ENT for CT or MRI imaging and specialist assessment.

Older adults: Posterior epistaxis is more common in older adults, related to arteriosclerotic vessel changes posteriorly and frequent anticoagulant use. Blood pressure control, anticoagulation review, and prompt specialist referral for persistent or posterior bleeds are the management priorities. Cardiorespiratory effects of posterior nasal packing — hypoxia and vasovagal responses — make hospital admission and monitoring mandatory in this age group.

Pregnancy: Mucosal engorgement during pregnancy increases epistaxis frequency. Conservative management — posture, pressure, saline spray, petroleum jelly — is appropriate. Topical oxymetazoline is generally considered low risk for brief use in pregnancy but should be limited to short courses. Co-phenylcaine contains phenylephrine, which should be used with caution during pregnancy; brief single-use for a GP procedure carries lower risk than prolonged use.

Hereditary haemorrhagic telangiectasia: HHT requires referral to the Australian HHT Association network and specialist care (haematology and ENT). Long-term management options include topical tranexamic acid, laser ablation of nasal telangiectasia, systemic anti-angiogenic therapy (bevacizumab in specialist settings), and screening for pulmonary, cerebral, and GI arteriovenous malformations.

People who use cocaine or methamphetamine: Intranasal stimulant use causes progressive vasoconstriction, mucosal ischaemia, and septal perforation — leading to recurrent bleeds from the perforation edges. The perforation cannot be repaired without addressing the underlying substance use disorder first; address harm reduction and substance use support alongside wound care.

When to escalate

Seek emergency assessment if:

• Bleeding does not stop after two full 15-minute periods of firm pressure
• The patient is haemodynamically compromised — faint, pale, hypotensive, or tachycardic
• A very large volume of blood has been swallowed or expelled
• Signs of posterior bleeding are present — blood appearing in the posterior pharynx, bilateral packing ineffective

Refer to ENT when:

• A posterior bleed is suspected or confirmed
• Anterior packing cannot be removed safely in the GP setting at review
• Recurrent or refractory anterior epistaxis despite optimal prevention measures
• Adolescent male with unilateral bleed and a possible nasal mass — do not biopsy; refer for imaging
• Adult, particularly of Asian background, with persistent unilateral epistaxis, cervical lymphadenopathy, or cranial nerve signs — nasopharyngeal carcinoma must be excluded
• Suspected HHT — refer to haematology and ENT; Australian HHT Association provides clinician guidance and specialist directories

Refer to haematology when:

• Suspected inherited coagulopathy such as von Willebrand disease or haemophilia
• Complex anticoagulation management in the context of recurrent significant bleeding
• HHT confirmed or suspected — pulmonary and cerebral AVMs require screening

What this article is and is not

This is general health information drawn from current Australian guidelines — Therapeutic Guidelines (eTG), Australian Medicines Handbook, NPS MedicineWise, ASOHNS, ASTH — and the AAO-HNS 2020 Nosebleed Clinical Practice Guideline. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about anticoagulation, nasal packing, referral, and specific management are made with your own GP and treating clinicians based on your individual history and medications.

For consumer information: HealthDirect — Nosebleeds, Better Health Channel, Australian HHT Association.

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Sources cited

1. Therapeutic Guidelines (eTG) — Otorhinolaryngology
2. Australian Society of Otolaryngology, Head & Neck Surgery (ASOHNS)
3. AAO-HNS Clinical Practice Guideline: Nosebleed (2020)
4. Australasian Society of Thrombosis and Haemostasis (ASTH)
5. Australian HHT Association
6. Australian Medicines Handbook (AMH)
7. NPS MedicineWise
8. PBS Australia
9. HealthDirect — Nosebleeds
10. MBS Online
11. Better Health Channel
12. RACGP