👃 Epistaxis in PLAB 2: When Is It Worrisome and What Should You Do?

Ann Augustin
Jun 25
2 min read

Updated: Jun 26

Epistaxis is a common presentation in UK general practice and emergency settings. While most nosebleeds are mild and self-limiting, PLAB 2 examiners are keen to see how you spot red flags, differentiate the type of bleed, and manage accordingly.

🩸 Types of Epistaxis: Know Your Anatomy

1. Anterior Epistaxis

Most common (~90%)
Arises from Kiesselbach’s plexus (Little’s area) on the anterior nasal septum
Easy to see and control
Common in children and young adults

2. Posterior Epistaxis

Less common but more dangerous
Arises from sphenopalatine artery (branch of internal maxillary artery) and Woodruff’s plexus (venous)
Common in the elderly, especially those with hypertension or on anticoagulants
Blood trickles down throat, may not be visible from the front

⚠️ Red Flags — When Is Epistaxis Worrisome?

Red Flag	Why It’s Worrisome
Bleeding >20 minutes	Suggests arterial or posterior source
Blood into throat / vomiting blood	Posterior epistaxis, aspiration risk
Recurrent frequent bleeds	Consider tumor, bleeding disorder
On anticoagulants or antiplatelets	Reduced clotting ability
Signs of shock (pallor, tachycardia, dizziness)	Significant blood loss
Unilateral, persistent bleeding	Consider nasal tumor (e.g., JNA, carcinoma)
Easy bruising, gum bleeds	Suspect coagulopathy or leukemia
Uncontrolled hypertension	Aggravates and prolongs bleeding
Recent nasal trauma / surgery	Risk of structural injury or skull base fracture
Age <2 years	Unusual—think abuse or clotting disorder

❓ Important Questions to Ask in History

Can you quantify the blood loss?
Is blood dripping down the throat?
Any previous episodes?
Are you taking warfarin, aspirin, or DOACs?
Any recent nasal trauma or facial injury?
Do you bruise easily or have family history of bleeding disorders?

🧬 Risk Factors for Epistaxis

🧱 Local (Nasal) Factors

Nose picking
Dry air or low humidity
URTIs
Allergic rhinitis
Nasal trauma
Deviated septum
Nasal foreign body
Nasal surgery or endoscopy
Nasal tumors (e.g., JNA, carcinoma)

🩸 Systemic Factors

Hypertension
Coagulation disorders (hemophilia, vWD)
Platelet disorders / thrombocytopenia
Liver disease
Leukemia
Hereditary hemorrhagic telangiectasia (HHT)
Granulomatosis with polyangiitis (GPA)

💊 Medications

Antiplatelets: Aspirin, Clopidogrel
Anticoagulants: Warfarin, DOACs
Nasal corticosteroids
NSAIDs

🌍 Demographic & Environmental

Older age
Winter or dry climates
Smoking

👩‍⚕️ GP Management: What Should You Do?

🔎 1. Assess and Stabilize

Check vital signs
Estimate blood loss
Examine nose and oropharynx

🧪 2. Investigate If Indicated

FBC, platelets
Coagulation profile (if on warfarin/DOACs)
U&E/LFTs if systemic cause suspected

🏥 3. Refer to ENT or A&E If:

Bleeding is posterior, profuse, or recurrent
Packing is required
Unilateral or suspicious mass present
Patient shows signs of hypovolemia
Persistent bleeds despite first aid

💊 4. Manage Underlying Causes

Adjust anticoagulation if needed
Control hypertension
Treat dryness with saline sprays or nasal lubrication

📅 5. Arrange Follow-Up If:

Bleeding was recurrent or required packing
The patient is elderly or on anticoagulants
Suspected underlying cause (e.g. mass, coagulopathy)

📢 Patient Discharge Advice

Pinch soft part of nose while leaning forward (10–15 mins)
Apply cold compress
Avoid nose blowing or heavy lifting for 48 hours
Use saline spray or Vaseline to prevent dryness
Seek medical help if bleeding recurs or becomes profuse

🧠 PLAB 2 OSCE Tips

Always ask about posterior symptoms (blood down throat)
Communicate clearly and calmly
Distinguish dangerous vs benign cases
Offer safety-netting and follow-up advice
Know when to refer or manage in GP

📚 References: