All EMS presentations
OtherClinical presentation

Epistaxis

A streamlined, differential-led presentation for rapid clinical review.

Clinical snapshot

Twenty-second review

  • Epistaxis usually arises from fragile anterior nasal vessels but may be posterior, traumatic, medication-related, or worsened by hypertension and anticoagulation.
  • Airway contamination, uncontrolled posterior bleeding, shock, major trauma, anticoagulation, or recurrent large-volume blood loss is high risk.
  • Keep hematemesis or hemoptysis in the differential; overlapping or concurrent illness remains possible.
  • For epistaxis, trends and combinations of findings are more informative than one isolated vital sign.
Differentials

Compare the clinical patterns

The repeated material is grouped inside each possibility. Open only the condition you need.

Serious2 conditions
Posterior hemorrhageTime-sensitive high-risk possibility

HPI

Clarify duration; still bleeding; unilateral/bilateral.

Signs & symptoms

Blood in pharynx, difficult control, trauma, or physiological compromise.

Focused exam

Limit examination to what is clinically necessary and consented to; Document objective findings, patient statements, and relevant negatives carefully.

Brief pathophysiology

Posterior hemorrhage may cause epistaxis through a time-sensitive process capable of rapid physiological deterioration.

Vital-sign pattern

What the trend may show

Possible pattern

Hemorrhage is a trend diagnosis: tachycardia and narrowing pulse pressure may precede hypotension. Age, pregnancy, medications, and pacing can blunt expected responses.

Heart rate (bpm)

Often rises

Tachycardia is a common compensatory response but may be absent.

Pulse pressure (mmHg)

May narrow

Narrowing pulse pressure can reflect reduced stroke volume.

Blood pressure (mmHg)

May fall late

A normal pressure does not exclude significant compensated hemorrhage.

MAP (mmHg)

May fall

A falling trend supports worsening perfusion; interpret with mental status and skin signs.

Front-load in the triage report

  • Posterior hemorrhage: Blood in pharynx, difficult control, trauma, or physiological compromise.
  • Duration.
  • Still bleeding?
Facial injuryTime-sensitive high-risk possibility

HPI

Clarify still bleeding; unilateral/bilateral; trauma.

Signs & symptoms

Blood in pharynx, difficult control, trauma, or physiological compromise.

Focused exam

Document objective findings, patient statements, and relevant negatives carefully; Have the patient lean forward; inspect visible source without deep instrumentation and assess airway, swallowed blood, perfusion, BP context, and medications.

Brief pathophysiology

Facial injury may cause epistaxis through a time-sensitive process capable of rapid physiological deterioration.

Vital-sign pattern

What the trend may show

Possible pattern

This differential does not have a diagnostic vital-sign signature. Heart rate, pressure, respiratory rate, and oxygenation are the four most useful observations for confirming physiologic stability and detecting an associated emergency.

Heart rate (bpm)

Trend from baseline

Explain persistent tachycardia or bradycardia rather than attributing it to distress alone.

Blood pressure (mmHg)

Trend from baseline

Hypotension or marked hypertension may change urgency and the differential.

Respiratory rate (breaths/min)

Trend rate / effort

Abnormal breathing can identify occult illness or injury.

Oxygen saturation (SpO₂)

Usually preserved

Low saturation suggests respiratory compromise or a concurrent condition.

Front-load in the triage report

  • Facial injury: Blood in pharynx, difficult control, trauma, or physiological compromise.
  • Still bleeding?
  • Unilateral/bilateral.
Common1 condition
Anterior epistaxisCommon presentation pattern

HPI

Clarify duration; still bleeding; unilateral/bilateral.

Signs & symptoms

Visible front-of-nose bleeding often responds to continuous compression.

Focused exam

Limit examination to what is clinically necessary and consented to; Document objective findings, patient statements, and relevant negatives carefully.

Brief pathophysiology

Anterior epistaxis may explain the presenting symptoms through a common clinical mechanism, while serial assessment checks for complications or an alternate cause.

Vital-sign pattern

What the trend may show

Possible pattern

This differential does not have a diagnostic vital-sign signature. Heart rate, pressure, respiratory rate, and oxygenation are the four most useful observations for confirming physiologic stability and detecting an associated emergency.

Heart rate (bpm)

Trend from baseline

Explain persistent tachycardia or bradycardia rather than attributing it to distress alone.

Blood pressure (mmHg)

Trend from baseline

Hypotension or marked hypertension may change urgency and the differential.

Respiratory rate (breaths/min)

Trend rate / effort

Abnormal breathing can identify occult illness or injury.

Oxygen saturation (SpO₂)

Usually preserved

Low saturation suggests respiratory compromise or a concurrent condition.

Front-load in the triage report

  • Visible front-of-nose bleeding often responds to continuous compression.
  • Duration.
  • Still bleeding?
Mimics2 conditions
HematemesisImportant alternative presentation

HPI

Clarify duration; still bleeding; unilateral/bilateral.

Signs & symptoms

Swallowed or coughed blood can confuse the source.

Focused exam

Limit examination to what is clinically necessary and consented to; Document objective findings, patient statements, and relevant negatives carefully.

Brief pathophysiology

Hematemesis can resemble epistaxis through overlapping symptoms or referred physiology despite a different primary mechanism.

Vital-sign pattern

What the trend may show

Possible pattern

This differential does not have a diagnostic vital-sign signature. Heart rate, pressure, respiratory rate, and oxygenation are the four most useful observations for confirming physiologic stability and detecting an associated emergency.

Heart rate (bpm)

Trend from baseline

Explain persistent tachycardia or bradycardia rather than attributing it to distress alone.

Blood pressure (mmHg)

Trend from baseline

Hypotension or marked hypertension may change urgency and the differential.

Respiratory rate (breaths/min)

Trend rate / effort

Abnormal breathing can identify occult illness or injury.

Oxygen saturation (SpO₂)

Usually preserved

Low saturation suggests respiratory compromise or a concurrent condition.

Front-load in the triage report

  • Swallowed or coughed blood can confuse the source.
  • Duration.
  • Still bleeding?
HemoptysisImportant alternative presentation

HPI

Clarify still bleeding; unilateral/bilateral; trauma.

Signs & symptoms

Swallowed or coughed blood can confuse the source.

Focused exam

Document objective findings, patient statements, and relevant negatives carefully; Have the patient lean forward; inspect visible source without deep instrumentation and assess airway, swallowed blood, perfusion, BP context, and medications.

Brief pathophysiology

Hemoptysis can resemble epistaxis through overlapping symptoms or referred physiology despite a different primary mechanism.

Vital-sign pattern

What the trend may show

Possible pattern

This differential does not have a diagnostic vital-sign signature. Heart rate, pressure, respiratory rate, and oxygenation are the four most useful observations for confirming physiologic stability and detecting an associated emergency.

Heart rate (bpm)

Trend from baseline

Explain persistent tachycardia or bradycardia rather than attributing it to distress alone.

Blood pressure (mmHg)

Trend from baseline

Hypotension or marked hypertension may change urgency and the differential.

Respiratory rate (breaths/min)

Trend rate / effort

Abnormal breathing can identify occult illness or injury.

Oxygen saturation (SpO₂)

Usually preserved

Low saturation suggests respiratory compromise or a concurrent condition.

Front-load in the triage report

  • Swallowed or coughed blood can confuse the source.
  • Still bleeding?
  • Unilateral/bilateral.
Red flags

Findings that should escalate concern

  • Airway contamination, uncontrolled posterior bleeding, shock, major trauma, anticoagulation, or recurrent large-volume blood loss is high risk.
  • Posterior hemorrhage or facial injury: Blood in pharynx, difficult control, trauma, or physiological compromise.
Related medications

Medication recognition

ApixabanRivaroxabanClopidogrelWarfarin
Related EMS presentations

Continue the clinical pathway

TraumaLaceration / external hemorrhageGIGI bleedRespiratoryHemoptysisHematologicBleeding while anticoagulated
References

Clinical and academic sources

Curated clinical guidance and peer-reviewed evidence supporting this presentation. Current BCEHS guidance, medical direction, and local policy remain authoritative for practice.

BCEHS Handbook — specific CPGs

  1. E11: EpistaxisBC Emergency Health Services Handbook

    Official BCEHS clinical practice guidance for epistaxis.

Supporting clinical and academic evidence

  1. CEDIS Presenting Complaint List updateCanadian Association of Emergency Physicians

    Presenting-complaint terminology and categorization context. It does not establish a prehospital “top 100” ranking.

  2. WHO Medical Emergency ChecklistWorld Health Organization

    A structured emergency assessment framework intended to reduce missed life-threatening conditions.

  3. Clinical Practice Guideline: Nosebleed (Epistaxis)Otolaryngology–Head and Neck Surgery · 2020

    Structured epistaxis assessment, compression, packing context, risk factors, and escalation.