Medical

Persistent nosebleed in a patient on aspirin

Foundation

Adult · 43yr · male

Patient Information

Dispatch	You are called to a 43-year-old male (Marcus Webb) at the Perth Royal Show who is sitting on a bench near the livestock pavilion with a cloth pressed to his face. A bystander says he has been bleeding from his nose for about 10 minutes and it is not stopping.
Patient	Marcus Webb — 43yr (84kg)
Incident History	Patient was walking through a crowded pavilion when he received an elbow to the nose from a passing bystander. Immediately developed brisk bleeding from the right nostril. Has been applying direct pressure with a cloth but bleeding has not stopped. No loss of consciousness. No head impact.
Emergency Contact	Claire Webb (Wife) — 0412 554 219

Initial Rapid Assessment

Response	Alert
Airway	Partially compromised — blood trickling into posterior pharynx. Patient swallowing frequently. Talking clearly between swallowing.
Breathing	Comfortable. RR 14. No respiratory distress. SpO2 99% on room air.
Circulation	Radial pulse strong and regular. Skin warm and dry. Ongoing blood loss from right nostril — soaked through cloth. CRT <2s.
Disability	GCS 15 (E4V5M6). Alert, orientated, mildly anxious.
Exposure	Right nostril — brisk bleeding from anterior nasal mucosa. No visible nasal deformity. Mild soft tissue swelling over the right nasal bridge. No periorbital bruising.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	99% (RA)	Nil	14	90	138/86	<2s	15	4 4 ++	36.7	–	4
20 mins	99% (RA)	Nil	14	84	132/84	<2s	15	4 4 ++	36.7	–	2

History Taking

Treatment Response

Diagnosis

Anterior epistaxis secondary to blunt nasal trauma, complicated by concurrent daily aspirin use which impairs platelet aggregation and prolongs bleeding. This is not a posterior bleed — blood is visible anteriorly and the patient is not bleeding heavily into the pharynx. Management is sustained anterior compression with correct technique. If bleeding is not controlled within 20 minutes, escalation to CSP is appropriate. Nasal deformity is possible but not present in this scenario — the nose is tender but not visibly displaced.

Facilitator Triggers — if trainees miss a critical step

! (If trainees instruct the patient to tilt his head BACK — patient begins swallowing large amounts of blood. Prompt: 'He is now swallowing a lot of blood — he says it tastes metallic and he feels queasy.' Facilitator note: tilting the head back causes blood to flow into the posterior pharynx and be swallowed or aspirated. The correct position is leaning FORWARD with the head tilted slightly down.)
! (If trainees do not ask the patient to pinch the SOFT part of the nose — facilitator prompts at 5 minutes: 'He is pinching the bridge of his nose — is that the correct technique?' Facilitator note: compression must be applied to the soft cartilaginous part of the nose, not the bony bridge, to occlude the bleeding vessels.)
! (If trainees do not continuously time the compression — prompt: 'How long has the compression been applied? When are you planning to reassess?' Facilitator note: compression should be sustained for at least 10–15 minutes without releasing to check.)
! (If trainees are not aware that aspirin affects bleeding — prompt: 'He mentions he takes aspirin daily — does that change your expectations for this bleed?' Facilitator note: aspirin inhibits platelet function and may prolong bleeding time. This is relevant to escalation decision-making.)
! (If bleeding is not controlled at 20 minutes — bleeding continues. Facilitator note: escalate to CSP. 20 minutes of correct anterior compression without cessation warrants further assessment — possible posterior bleed, or significant antiplatelet effect preventing clotting.)

Treatment Objectives

1. Ensure scene safety — move patient away from the crowded area to the FAP.
2. Don appropriate PPE — gloves essential; blood exposure risk is high.
3. Perform Primary Survey — confirm patent airway (blood trickling into pharynx warrants vigilance), adequate breathing, adequate circulation.
4. Position patient correctly — seated, leaning FORWARD with head tilted slightly down. Do NOT tilt the head back.
5. Instruct patient to breathe through his mouth.
6. Apply sustained compression to the SOFT, cartilaginous portion of the nose — not the bony bridge — for a minimum of 10–15 minutes without releasing to check.
7. Confirm compression technique — the patient must pinch firmly enough to occlude the nasal passage.
8. Start timing compression from when correct technique is confirmed.
9. Conduct SAMPLE / IMISTAMBO history — specifically note aspirin use, which impairs platelet aggregation and may prolong bleeding time.
10. Complete Vital Sign Survey — BP 138/86, HR 90, SpO2 99%, GCS 15. Note slightly elevated BP consistent with pain and anxiety.
11. Do NOT pack the nose — packing is not within EHS scope.
12. After 10–15 minutes, gently release pressure and assess whether bleeding has stopped — if not, reapply for a further 10 minutes.
13. If bleeding is controlled — advise patient to avoid blowing the nose, sneezing forcefully, or inserting anything into the nose for the next 24 hours.
14. Assess for nasal deformity or septal haematoma — if midline deviation or boggy septal swelling is noted, arrange medical review.
15. If bleeding is NOT controlled after 20 minutes of correct sustained compression — contact CSP. Given aspirin use, this patient may require further assessment and possible nasal cauterisation or packing by a clinician.
16. Monitor for signs of significant blood loss — pallor, tachycardia, hypotension.
17. Scenario ends when bleeding is controlled and patient is given appropriate advice, OR when CSP handover is arranged.
18. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Primary Survey · Secondary & CNS Survey · Bleeding Control · Blood Pressure · Pulse & Respirations

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Signs/Symptoms	Bleeding from right nostril following blunt nose injury. Blood trickling into the throat. No headache. No visual changes. No dizziness.
Allergies	NKDA.
Medications	Aspirin 100mg daily (commenced 3 months ago following a cardiac stress test showing minor ischaemic changes — cardiologist follow-up pending). No other medications.
Pertinent History	No prior history of nosebleeds. No known clotting disorder. No hypertension. Aspirin commenced post-cardiac investigation — patient denies any formal cardiac diagnosis. Non-smoker. Mild stress at work.
Last Oral Intake	Lunch approximately 2 hours ago.
Events Leading	Patient was attending the Royal Show with his family. Was bumped on the nose by a bystander's elbow in a crowded pavilion. Bleeding started immediately and has not settled despite sustained pressure.
Treatment Prior	Self-applied direct pressure with cloth for approximately 10 minutes before EHS arrival — bleeding has not stopped.

Onset	Approximately 10 minutes prior to EHS arrival, following a blunt impact to the nose from a bystander's elbow.
Pain	Mild tenderness over the right nasal bridge. Pain 4/10.
Quality	Dull aching tenderness at the point of impact.
Radiates	Nil radiation.
Severity	4/10.