What are the red flags for nosebleed (epistaxis) in urgent care?

Haemodynamically unstable or heavy ongoing bleeding → ED — resuscitate, pack, ENT; Bleeding from both nostrils / posterior → Posterior bleed — ENT; On warfarin with high INR, or bleeding disorder → Check INR / FBC; ENT / haematology advice; Unilateral recurrent bleeds with obstruction in an older adult → Possible tumour — ENT referral

What should I prescribe for nosebleed (epistaxis)?

Naseptin cream (chlorhexidine + neomycin): Apply inside the nostril four times a day (10 days. Contains arachis (peanut) oil — avoid in peanut/soya allergy (use mupirocin nasal ointment per local guidance))

Epistaxis: First Aid, Cautery & Naseptin | Urgent Care Clinic

Q: What safety-netting advice should I give for nosebleed (epistaxis)?

Advise the patient to return or seek help if: Bleeding doesn’t stop after 20 minutes of proper pressure; Very heavy bleeding, feeling faint or short of breath; Frequent repeat bleeds.

1Rule out first — red flags

If you find…	…then
Haemodynamically unstable or heavy ongoing bleeding	ED — resuscitate, pack, ENT
Bleeding from both nostrils / posterior	Posterior bleed — ENT
On warfarin with high INR, or bleeding disorder	Check INR / FBC; ENT / haematology advice
Unilateral recurrent bleeds with obstruction in an older adult	Possible tumour — ENT referral

2Focused history

Side, duration, volume; first or recurrent
Anticoagulants / antiplatelets, bleeding disorders
Trauma, nose picking, recent URTI
Hypertension; liver disease; HHT family history

3Focused examination

Obs
Anterior rhinoscopy after clearing clots (Little’s area)
Back of the throat for posterior bleeding

4Decide — investigate only if it changes the plan

Investigation	Only if…
FBC, clotting / INR	Heavy bleeding, recurrent, or on anticoagulants

5Treat & send home

Management & advice

First aid: sit forward, pinch the soft part of the nose firmly for 10–15 min without releasing; ice on the bridge or sucking ice
If a bleeding point is visible: silver nitrate cautery (one side at a time; numb first)
If still bleeding: nasal pack and ENT referral
Advice: avoid nose blowing, picking, heavy lifting, hot drinks and alcohol for a few days

Refer / follow-up

Packing needed, posterior bleed, recurrent despite cautery → ENT

℞

Discharge prescription (TTO)Typical adult doses — check the BNF/BNFc, allergies, renal function, pregnancy and interactions.

Drug	Dose	Duration / notes
Naseptin cream (chlorhexidine + neomycin)	Apply inside the nostril four times a day	10 days. Contains arachis (peanut) oil — avoid in peanut/soya allergy (use mupirocin nasal ointment per local guidance)

6Safety-net

Say it like this

If it starts again: sit up, lean forward and pinch the soft part of your nose firmly for 15 minutes by the clock without letting go. Use the cream four times a day for 10 days. Don’t blow or pick your nose for a few days. If it won’t stop after 20 minutes of pressure, or it’s very heavy, come back or call 999.

Come back / call 111 — or 999 if severe — if:

Bleeding doesn’t stop after 20 minutes of proper pressure
Very heavy bleeding, feeling faint or short of breath
Frequent repeat bleeds

7Patient leaflets — scan & go

Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.

Nosebleednhs.uk/conditions/nosebleed

8Document

Nosebleed (epistaxis) — clinic note

A structure to document efficiently. It is not a completeness check — use your trust’s system and your clinical judgement.

URGENT CARE — NOSEBLEED (EPISTAXIS) PRESENTING COMPLAINT: HISTORY Side, duration, volume; first or recurrent: Anticoagulants / antiplatelets, bleeding disorders: Trauma, nose picking, recent URTI: Hypertension; liver disease; HHT family history: RED FLAGS (record present / absent) [ ] Haemodynamically unstable or heavy ongoing bleeding [ ] Bleeding from both nostrils / posterior [ ] On warfarin with high INR, or bleeding disorder [ ] Unilateral recurrent bleeds with obstruction in an older adult PMH: DRUG HISTORY: ALLERGIES: SOCIAL (job / who is at home / driving): OBSERVATIONS: RR SpO2 HR BP Temp (NEWS2 ) EXAMINATION Obs: Anterior rhinoscopy after clearing clots (Little’s area): Back of the throat for posterior bleeding: INVESTIGATIONS: none required / FBC, clotting / INR — result: IMPRESSION: PLAN Treatment / TTO (drug, dose, duration): Advice given: Leaflet given (QR / printed): Nosebleed Follow-up / referral: SAFETY-NETTING (told to return / call 111 / 999 if): - Bleeding doesn’t stop after 20 minutes of proper pressure - Very heavy bleeding, feeling faint or short of breath - Frequent repeat bleeds Patient understands and agrees with the plan: Y / N Seen by: Grade: Date/Time:

✓Guidelines

NICE CKS — Epistaxis (nosebleeds)

Doses are typical adult doses drawn from the guidance above. Always check the current BNF/BNFc and your local antimicrobial policy.

More ear, nose, throat & eyes

Sore throat & tonsillitisFeverPAIN decides — and don’t miss the quinsy or epiglottitis.Earache: otitis media & externaMostly no antibiotics — but spot mastoiditis and malignant otitis externa.SinusitisViral until day 10 — and don’t miss the orbit.Red eye & conjunctivitisConjunctivitis is a diagnosis of exclusion — check acuity and pain first.