guidelines

epistaxis (nosebleed)

nice cks-aligned primary care approach: first aid, topical measures, anticoagulants, when to pack/refer, and safety-netting for posterior or severe bleeds.

last reviewed: 2026-02-14
based on: NICE CKS Epistaxis (accessed 2026)
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Executive summary

  • First aid: sit forward, pinch the soft part of the nose continuously for 10–15 minutes, spit blood out (don’t swallow).
  • Reassess: if bleeding persists, repeat compression; consider topical vasoconstrictor/local anaesthetic where available (UTC/ENT pathways).
  • Escalate urgently if haemodynamic compromise, significant ongoing bleed, suspected posterior bleed, or failure of simple measures.
  • Anticoagulants: do not stop without a plan; if severe bleed or recurrent, discuss with anticoagulation/ENT and follow local major haemorrhage protocols when indicated.

When to refer same-day / call 999

  • Signs of shock, syncope, large volume bleeding, airway compromise, or ongoing uncontrolled bleeding.
  • Suspected posterior epistaxis (bleeding into throat, bilateral bleeding, difficulty visualising anterior source, older patient on anticoagulants).
  • Recurrent heavy epistaxis, significant comorbidity, anaemia, or inability to comply with home safety-netting.

References (Harvard):

  • NICE CKS (2026) Epistaxis. https://cks.nice.org.uk/topics/epistaxis/

FAQs

Lean head back or forward?
Forward. Leaning back increases swallowing of blood and nausea/vomiting.
How long should pressure be applied?
Continuous pressure for 10–15 minutes to the soft part of the nose, then reassess.
What about patients on anticoagulants?
Use a lower threshold for escalation. Don’t stop anticoagulants casually—coordinate with anticoagulation/ENT and follow local pathways if severe.

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.