CCFP priority topic 37 of 105
Epistaxis on the CCFP exam
7 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 7 key features for Epistaxis. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 7
Is the patient stable?
Decide from the history and exam whether blood loss has made the patient unwell.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Choosing Wisely Canada
On the exam
An infant oozing from the nose for most of an hour, and a frightened mother. Expect a short menu (pick several from a list).
Pick the findings that show stability.
Common mistakes
Ordering iron tests or preparing a transfusion because the mother fears blood loss. A pink infant with a normal heart rate and brisk capillary refill is stable.
Approach
- Check heart rate, blood pressure, capillary refill, colour and alertness first.
- In a child, a fast heart rate shows blood loss before blood pressure falls.
- Ask how long it has bled, how heavily, from one side or both, and whether blood is being swallowed or vomited.
- Dizziness, fainting, pallor or a racing heart point to major loss. Treat shock first: an intravenous (IV) line, fluids, blood work and early help.
- Decide on blood by the patient's state and the cause, not by a hemoglobin number alone.
- Don't transfuse when something safer works as well. Iron deficiency without instability is treated with iron.
Key feature 2 of 7
Calm the room
While the nose is bleeding, notice and ease the fear of the patient and family.
CFPC skill Patient-centred approach, clinical reasoningPhase Treatment, diagnosis
On the exam
Parents panic while their infant bleeds, and the father demands packing. Expect one best answer.
Pick the best next step.
Common mistakes
Sending the parents out. The infant screams harder and bleeds more. Packing because the father insists is wrong too: correct pressure has not been tried.
Approach
- Name the fear out loud. Say that a nosebleed often looks worse than it is.
- Keep the parent in the room. Seat the infant upright on a parent's lap, leaning forward.
- Give the parent a job, such as holding the child still while you press.
- Crying raises pressure in the veins of the nose. A calm, held child bleeds less.
- Explain each step before you do it, and what comes next if pressure fails.
- Fear and pain raise blood pressure. Recheck it once the patient is calm.
Key feature 3 of 7
Find the cause
After a nosebleed, take a short history aimed at the likely causes.
CFPC skill Clinical reasoningPhase History, hypothesis generationSources Choosing Wisely Canada
On the exam
A girl of 8 with repeat bleeds from one nostril, soon after starting a nasal spray. Expect a short menu (pick several from a list).
Pick the history that finds the cause.
Common mistakes
Blaming her allergy or dry winter air and stopping there. The bleeds began with the spray, so ask how she aims it. Asking about headache or high blood pressure wastes picks when her vital signs are normal.
Approach
- Ask about nose picking, a recent cold, hard nose blowing and dry air.
- Ask about nasal sprays. A steroid spray aimed at the septum, the wall between the nostrils, can start one-sided bleeds.
- Ask about blood thinners such as warfarin or apixaban, antiplatelets such as ASA, and anti-inflammatory pain pills.
- Ask about bleeding elsewhere: easy bruising, gum bleeding, heavy periods, bleeding after dental work, or a family history.
- After a blow to the nose, look for a soft, swollen bulge on the septum. Don't order a plain X-ray for a suspected broken nose.
- One-sided blockage and a bad smell in a young child suggests something pushed up the nose. In a teenage boy, think of a rare benign tumour.
Key feature 4 of 7
Find and stop it
Look for the bleeding point at the front of the nose, then control it step by step.
CFPC skill Clinical reasoning, procedure skillsPhase Physical, treatment
On the exam
A school-age child with repeat bleeds from one nostril and a visible vessel. Expect one best answer for treatment.
Pick the best treatment.
Common mistakes
Ice on the bridge and lying back: blood runs down the throat, and cold on bone presses nothing. Cauterizing both sides of the septum at once is wrong too.
Approach
- Seat the patient upright, leaning forward, mouth open. Spit blood out rather than swallow it.
- Pinch the soft lower part of the nose, below the bone. Hold it without letting go to check.
- Clear the clots, then look with a good light and a nasal speculum.
- Most bleeds start at the front of the septum. Look there first.
- Cauterize a visible vessel on one side only. Both sides at one sitting can leave a hole in the septum.
- A cooperative child with one front vessel can be treated in the office. General anesthesia brings risks and a wait.
| Step | Use when | Know this |
|---|---|---|
| Firm pressure | Every front bleed, first | Sit up, lean forward, pinch the soft nose. Not ice, not lying back. |
| Cautery | A vessel you can see | One side of the septum only. |
| Front packing | Bleeding goes on, or no source is seen | Painful. Plan its removal. Only after correct pressure. |
Key feature 5 of 7
Think further back
When bleeding goes on or comes back after treatment, suspect a source deep in the nose.
CFPC skill Clinical reasoningPhase Hypothesis generation
On the exam
An older man on a blood thinner, still bleeding into his throat with a front pack in. Expect one best answer.
Pick the next step.
Common mistakes
Repacking the front and sending him home. The opposite error: calling repeat bleeds from one visible front vessel in a child posterior, or a bleeding disorder.
Approach
- Suspect a source at the back when blood runs down the throat despite a well-placed front pack.
- Other clues: bleeding from both nostrils, brisk flow, and no source seen at the front.
- It is more likely in older adults and in people on blood thinners.
- Treat it as an emergency. Protect the airway, place an IV line and send blood work.
- Call ear, nose and throat (ENT) surgery. A back pack or balloon needs a trained hand and a hospital bed.
- A child who rebleeds from the same visible front vessel has a front bleed. Cauterize it rather than wait longer.
- Ask why treatment failed: a blood thinner, a bleeding disorder, or a poorly placed pack.
| Front (anterior) | Back (posterior) | |
|---|---|---|
| Who | Children and younger adults, most often | Older adults, often on blood thinners |
| Signs | One nostril; a source you can see | Blood down the throat; both nostrils; no front source |
| First step | Pressure, then cautery or packing | Airway, IV line, urgent ENT call |
| Where | Office or urgent care | Hospital, often admitted |
Key feature 6 of 7
Tests only for a reason
Order blood tests for a nosebleed only when the history or exam gives a clear reason.
CFPC skill Clinical reasoning, selectivityPhase Investigation, hypothesis generationSources Choosing Wisely Canada
On the exam
A well child with brief repeat bleeds from one side, and a mother who wants a leukemia test. Expect a short menu (pick several from a list).
Pick the tests to order, if any.
Common mistakes
A clotting screen, blood count or von Willebrand panel for a well child with one visible vessel. Skipping tests is wrong when an infant's history suggests a bleeding tendency.
Approach
- Order blood work only for a reason: the patient is unstable, bleeding heavily, on a blood thinner, or shows signs of a bleeding disorder.
- Signs of a bleeding disorder: bleeding at other sites, bleeds that are long or hard to stop, or a family history.
- A nosebleed in an infant is unusual. A history that hints at a bleeding tendency or at injury earns tests.
- On warfarin, with the bleed stopped and the INR high: hold warfarin or give vitamin K, not plasma. Save prothrombin complex concentrate for serious bleeding.
- Don't order a broad viral swab panel for the cold. A viral illness is diagnosed by its signs, and the panel rarely changes care.
- In a well child with a local cause, a borderline result adds worry, not answers.
Key feature 7 of 7
Going home
Before the patient leaves, teach how to prevent and treat the next bleed, and when to come back.
CFPC skill Clinical reasoningPhase Treatment, follow-up
On the exam
A child going home after cautery, with worried parents. Expect a short menu (pick several from a list) of advice.
Pick the advice to give.
Common mistakes
Teaching the parents to tilt the head back or hold ice on the nose. Or sending the family home with no plan for when to come back.
Approach
- Teach first aid: sit up, lean forward, pinch the soft nose without peeking, and spit out blood.
- Keep the inside of the nose moist, and use a humidifier in dry weather.
- After cautery, avoid picking, hard blowing, heavy lifting and straining for a few days.
- Aim a steroid spray toward the outer wall of the nostril, away from the septum.
- Come back if pressure fails, the bleed is heavy, the patient feels faint, or bruising or bleeding appears elsewhere.
- Packing in place: book its removal. Return sooner for fever, a rash or feeling very unwell.
- Plan follow-up. Bleeds that keep coming from the same vessel need cautery or referral.
Flashcards
Answer it first, then check.
KF 1An infant bled for most of an hour but is pink with brisk capillary refill. Transfuse?
No. The infant is stable. Find the bleeding point and stop the bleed instead. Source: Choosing Wisely Canada
KF 2A father begs you to pack his crying infant's nose. What comes first?
Calm the parents and seat the infant upright on a lap. Then try correct pressure.
KF 3One-sided bleeds began soon after a steroid nasal spray. What is the likely cause?
The spray hitting the septum. Teach the patient to aim it toward the outer wall.
KF 4Where do most nosebleeds start, and where do you look first?
At the front of the septum, the wall between the nostrils. Look there first.
KF 4A vessel bleeds on the right septum only. Why not cauterize both sides?
Burning both sides of the septum at one sitting can leave a hole in it.
KF 5A front pack is in, but blood still runs down the throat. What do you think of?
A bleed at the back of the nose. Protect the airway and call ENT urgently.
KF 6On warfarin, a high INR, and the nosebleed has stopped. Give plasma?
No. Hold warfarin or give vitamin K. Prothrombin complex concentrate is for serious bleeding. Source: Choosing Wisely Canada
KF 7Which head position do you teach the family for the next nosebleed?
Sit up and lean forward. Tilting the head back sends blood down the throat.
FAQ
Which guideline does the exam follow for nosebleeds?
The CFPC names none for this topic. The exam tests standard practice: check stability, calm the family, press correctly, find the front source, and test only for a reason.
Does high blood pressure cause nosebleeds?
The link is weak, even in adults. A high reading during a bleed often comes from fear and pain. Stop the bleed first, then recheck once the patient is calm.
Can a family doctor cauterize a child's nose?
Yes, in a cooperative child with one visible vessel at the front. Cauterize one side only. General anesthesia brings risks and a wait the child does not need.
When is a nosebleed in a child a warning sign?
When it comes with bruising, pallor, enlarged glands, bleeding elsewhere or a family history. Also one-sided blockage in a teenage boy, and any real nosebleed in an infant.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada