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Year : 2019  |  Volume : 7  |  Issue : 3  |  Page : 108-112

Awareness of first-aid management of epistaxis among school students in Jeddah, Saudi Arabia

Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Web Publication4-Nov-2019

Correspondence Address:
Khalid A Alshehri
Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, PO Box 23456, Jeddah 4534
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ssj.ssj_26_19

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Objective: The objective of this study was to assess the level of awareness regarding primary home management of epistaxis among high- and middle-school students and their teachers.
Materials and Methods: This cross-sectional study was conducted in December 2018 by distributing a paper-based questionnaire to high-and middle-school students and teachers in Jeddah, Saudi Arabia.
Results: The study included 706 individuals (53.4% males and 46.6% females) with a mean age of 16.58 ± 5.57 years. Based on the correlation between our variables, 57.5% of the participants had a good knowledge score, while only 3.5% had an excellent score. Male high-school students were significantly more knowledgeable than female middle-school students.
Conclusion: Awareness of first-aid management of epistaxis was fair. However, more integrated educational resources should be made available for the general population and school students and teachers.

Keywords: Awareness, epistaxis, first-aid

How to cite this article:
Alshehri KA, Alqulayti WM, Saggaf OM, Enani MZ, Bahatheq AK, Abdalwassie LK, Marzouki HZ. Awareness of first-aid management of epistaxis among school students in Jeddah, Saudi Arabia. Saudi Surg J 2019;7:108-12

How to cite this URL:
Alshehri KA, Alqulayti WM, Saggaf OM, Enani MZ, Bahatheq AK, Abdalwassie LK, Marzouki HZ. Awareness of first-aid management of epistaxis among school students in Jeddah, Saudi Arabia. Saudi Surg J [serial online] 2019 [cited 2023 Jun 11];7:108-12. Available from: https://www.saudisurgj.org/text.asp?2019/7/3/108/270240

  Introduction Top

Epistaxis is defined as bleeding from the nose or the nasal cavity.[1] It is the most frequently encountered ear, nose, and throat (ENT) emergency,[2] which has a bimodal incidence with peak incidence in people aged <10 years and >70 years.[3] Several researchers have reported that about 10%–60% of people have suffered from at least one previous significant episode of epistaxis.[1],[4],[5] Epistaxis constitutes 1 in 200 emergency department (ED) visits in the United States.[3] Moreover, Danielides et al. have reported an increase in the frequency of epistaxis during the winter.[6] The nasal cavity is highly vascularized by branches of both internal and external carotid arteries. The etiology of epistaxis remains unclear in the majority of cases and can be classified into local causes related to the nose, paranasal sinuses, and the nasopharynx or systemic causes (i.e., hypertension, blood dyscrasias, and use of anticoagulant medications).[6] Risk factors for epistaxis in children include nose picking, trauma, nasopharyngeal mass, bacterial nasal colonization, and allergic rhinitis.[7],[8],[9]

The severity of epistaxis ranges from mild to severe. Approximately, 90% of epistaxis cases arise from Little's area on the anterior part of the nasal septum and are typically mild in severity and seen in children aged <10 years. The remaining cases arise from the posterior nose and are usually more severe and occur in individuals aged >50 years.[10],[11] Epistaxis usually stops spontaneously or can be controlled at home conservatively with measures such as simple digital pressure over the ala nasi, pinching of the nose, and pouring cold water on the face. However, some cases can be very severe and life-threatening,[12] which may require active intervention and hospital admission. Several options are available to treat a nonstopping nasal bleed, such as bleeding point cauterization, anterior and/or posterior nasal packing, and ligation or embolization of the feeding vessels.[13],[14]

Epistaxis usually occurs in nonhospital settings, and most cases can be controlled by simple first-aid measures. These measures can be easily applied by nonmedical personnel at the site of the event until recovery or professional medical care is sought. Therefore, it is very important for nonmedical personnel (i.e., parents, teachers, and classmates) to understand first-aid measures for epistaxis. Therefore, we aimed to assess the awareness and knowledge among school students and teachers regarding the primary first-aid measures for home management of epistaxis.

  Materials and Methods Top

Study design and setting

This was an observational, cross-sectional study conducted among male and female high- and middle-school students and teachers in Jeddah, Saudi Arabia, during December 2018. All data were obtained using a paper-based-questionnaire, which was distributed to participants after they received a complete explanation of the purpose of this study, and informed written consent was attained before filling out the questionnaire.

Participants and data collection

There were a total of 706 students and teachers, including both sexes, who responded to the questionnaire. The questionnaire was adapted from a previous study,[15] which consisted of two parts. The first part contained questions about the demographic data of the respondents (i.e., age, nationality, sex, place of residence, and educational level). The second part included 10 true/false questions regarding the sources of information and knowledge about epistaxis.

Measurement and scoring

Knowledge was assessed on the basis of correct answers to six main questions about the first-aid management of epistaxis, which included the following: applying pressure on the nose, correct location on the nose where pressure should be applied, duration of applied pressure, tilting of the head, and packing and use of ice packs to control bleeding. Each correct answer was awarded 1 point, and the total scores for all questions were obtained. The level of knowledge was graded as follows: 5–6 correct responses, excellent knowledge; 3–4 correct responses, good knowledge; and ≤2 correct answers, poor knowledge.

Data analysis

All data were analyzed using the Statistical Package for the Social Sciences version 22 (IBM Corp., Armonk, NY, USA). Descriptive statistics are reported as frequencies and percentages, while continuous variables are presented as means ± standard deviations. Chi-squared test was used to assess the statistical significance. P <0.05 was considered statistically significant.

Confidentiality and ethical approval

The study protocol was reviewed and approved by the Institutional Review Board and the study was conducted in accordance with the 1975 Declaration of Helsinki (revised in 2008). Identifying information such as participant names, contact numbers, and addresses were not asked in the questionnaire to guarantee confidentiality of the participants.

  Results Top

The present study included 706 individuals (53.4% males and 46.6% females) with a mean age of 16.58 ± 5.57 years. Of these, 338 (47.2%) participants were in high-school, 333 (47.9%) were in middle-school, and the remainder were teachers (5.0%). The majority of participants (653; 92.5%) were from Saudi Arabia. Approximately 40.4% of participants reported that they had a prior epistaxis episode, and 189 (26.8%) participants had previously treated someone with epistaxis. Only 161 (22.8%) participants had undertaken a first-aid course [Table 1].
Table 1: Demographic characteristics of the sample (n=706)

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In the true/false questionnaire, the second question (“I will try to stop the bleeding by changing the position of my head”) received the highest rate of correct answers (78.8%). However, the lowest rate of correct answers (38.2%) was observed for the question: “Hot beverages exacerbate epistaxis.” The percentage of correct answers for the remaining questions is shown in [Table 2].
Table 2: The percentage of responses to the true\false epistaxis questionnaire among the sample (n=706)

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Regarding the multiple choice questions, 575 (81.4%) of participants mentioned that if they experienced epistaxis, they would try to stop or control it by applying pressure rather than doing nothing. Approximately 20.7% and 36.5% of participants mentioned that they would apply pressure to the bottom and upper part of the nose, respectively, to control epistaxis; 42.8% of participants were unaware about the location of pressure application. Regarding the change in head position (question 14), most participants (458 [64.9%]) reported that they will tilt their head backward during epistaxis. Data for other questions are shown in [Table 3].
Table 3: The percentage of responses to the multiple choice epistaxis questionnaire among the sample (n=706)

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Most participants thought that the best source for information to improve their knowledge regarding epistaxis management was a first-aid course (33.0%), followed by learning from doctors and social media (26.8% and 19.1%, respectively), and the lowest percentages were found for leaflets (1.0%) and daily newspapers (0.3%).

Based on the correlation analysis between our variables and the overall score, 57.5% of participants had a good score, while only 3.5% had an excellent score. A higher percentage of males achieved a good score compared to females. Therefore, sex was the only significant factor that affected the total score of knowledge related to the first-aid management of epistaxis [Table 4]. In the multivariate regression analysis, the question “Have you treated anyone with epistaxis?” was the only significant variable associated with the level of knowledge of first aid for epistaxis (R = 0.093, confidence interval = 0.002–0.185, P = 0.045).
Table 4: Levels of knowledge of the first aid management of epistaxis among the sample (n=706)

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  Discussion Top

Epistaxis is one of the most common ENT emergencies representing about 1.7% of all ED visits.[3] In addition, about 1 out of 200 ED visits in the United States is mainly due to epistaxis.[3] In a population-based cohort study among Scottish hospitals, 33% of all ENT emergent admissions were reported to be due to epistaxis.[2] As an emergency, epistaxis is not only important for professional health-care providers, but also the general population because it can happen anywhere and to anyone regardless of age or sex. In a similar study regarding the level of knowledge of managing epistaxis, only 11.3% of the study population who were clinical staff at the Accident and Emergency Department in Kenya were aware of how to properly manage epistaxis.[16] The authors of this previous study also demonstrated a lack of knowledge among health professionals.[16] In another study among health professionals, <40% of participants were aware of how to correctly apply pressure to the nose.[17] Approximately, 63.2% of the population of Saudi Arabia had a poor level of awareness regarding epistaxis first-aid management.[15] The knowledge scores obtained in our current study (i.e., good score of 57.5% and an excellent score of 3.5%) were relatively congruent to the general population despite including a relatively young study population. However, these results should not be interpreted with confidence because we only assessed two schools that are known to have good education in the city of Jeddah. Its reported that the general population has a poor understanding regarding the management of epistaxis and its first-aid measures.[18] Therefore, more effort is needed in educating populations. To the best of our knowledge, this was one of the very few studies conducted to investigate the knowledge of epistaxis management in schools. Furthermore, this was one of few studies conducted in Saudi Arabia, which shows the need for more research in the field.

Almost 80% of our participants answered, “I will try to stop the bleeding by changing the position of my head;” however, 65% of participants answered that “they will tilt their head backward during the event of epistaxis.” We cannot make conclusions solely from the first question because the later question, which reflects more knowledge depth and is important in epistaxis management for preventing direct blood to the posterior pharynx, was answered incorrectly. In contrast, a recent study in Saudi Arabia used the same questionnaire as our study and reported that only 15% of the population selected lowering their heads backward as part of epistaxis management.[15] This might be easily explained by the age differences between the two studies.

Based on our study results, males had a higher level of knowledge than females. However, we had a limited number of participating schools in this study, and most of our male participants were high-school students, while the majority of female participants were from middle-schools (6th to 9th grade in some school systems). The age difference might be a confounder and may have influenced biases in our results. Similar studies with a wider population distribution should be conducted in the future. After conducting multivariate regression analysis, the question, “Have you treated anyone with epistaxis?” was significantly correlated with the level of knowledge regarding the first-aid management of epistaxis among our participants. Students and teachers who previously experienced epistaxis themselves or had to help someone with epistaxis prior to commencing our study may have developed an interest in learning more about its management to improve their knowledge and action.

Although social media is a main source of information for this age group, the majority of our participants selected that a first-aid course would be the best source of information to increase their awareness regarding epistaxis, followed by information from doctors and social media. These sources of information should not be ignored because they all have the potential to increase the spread of awareness in different targeted populations.

Our biggest challenge in this study was to gain participation and cooperation from the schools. This is also a limitation in itself because we assumed that schools who refused to participate in the study were less confident regarding the level of knowledge of their students and teachers, whereas the included schools were more open minded to the study and aware of its important role.

Although increasing the sample size is always a useful recommendation, increasing the number of schools for collecting the data will help obtain more widespread demographics and decrease the occurrence of any bias. Furthermore, changing the method of measuring the level of knowledge from a paper-based questionnaire to an interview will decrease the chance of correctly guessing the answers. The way the questions are designed or written can also influence how the participants answer them. Conducting social campaigns in public areas and schools will improve the level of knowledge regarding epistaxis management among school students and the general population.

  Conclusion Top

The level of knowledge and awareness regarding the first-aid management of epistaxis among school students and teachers was shown to be satisfactory. However, more integrated educational materials should be made available to the general population as well as school students and staff to improve their overall knowledge in this area.


We are grateful for Mazen Mohammed Humayran, Abdelelah Hesham Mofti, Mahmood A Eid, and Jumanah Ali Bafail for participating as data collectors in the research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Albouq N, Aljeraisi T, Arabi S, Neyaz H, Alkhurassi H, Alim B. Knowledge and attitude regarding first aid management of epistaxis among medical specialties students in Al-Madinah, Kingdom of Saudi Arabia. Eur J Pharm Med Res 2017;4:264-7.  Back to cited text no. 1
Walker TW, Macfarlane TV, McGarry GW. The epidemiology and chronobiology of epistaxis: An investigation of Scottish hospital admissions 1995-2004. Clin Otolaryngol 2007;32:361-5.  Back to cited text no. 2
Pallin DJ, Chng YM, McKay MP, Emond JA, Pelletier AJ, Camargo CA Jr. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med 2005;46:77-81.  Back to cited text no. 3
Petruson B, Rudin R. The frequency of epistaxis in a male population sample. Rhinology 1975;13:129-33.  Back to cited text no. 4
Almulhim KS, Abdulhakim I, Mubarak AS, Hussain MA, Alhaddad MS, Alotaibi NK, et al. Assessment of knowledge attitude and practice of epistaxis in Saudi population. Egypt J Hosp Med 2017;69:2675-9.  Back to cited text no. 5
Danielides V, Kontogiannis N, Bartzokas A, Lolis CJ, Skevas A. The influence of meteorological factors on the frequency of epistaxis. Clin Otolaryngol Allied Sci 2002;27:84-8.  Back to cited text no. 6
Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med 2009;360:784-9.  Back to cited text no. 7
Douglas R, Wormald PJ. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg 2007;15:180-3.  Back to cited text no. 8
Whymark AD, Crampsey DP, Fraser L, Moore P, Williams C, Kubba H. Childhood epistaxis and nasal colonization with Staphylococcus aureus. Otolaryngol Head Neck Surg 2008;138:307-10.  Back to cited text no. 9
Bernius M, Perlin D. Pediatric ear, nose, and throat emergencies. Pediatr Clin North Am 2006;53:195-214.  Back to cited text no. 10
McGarry GW, Moulton C. The first aid management of epistaxis by accident and emergency department staff. Arch Emerg Med 1993;10:298-300.  Back to cited text no. 11
Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician 2005;71:305-11.  Back to cited text no. 12
Badran K, Arya AK. An innovative method of nasal chemical cautery in active anterior epistaxis. J Laryngol Otol 2005;119:729-30.  Back to cited text no. 13
Feusi B, Holzmann D, Steurer J. Posterior epistaxis: Systematic review on the effectiveness of surgical therapies. Rhinology 2005;43:300-4.  Back to cited text no. 14
Saleem AH, Alahwal AM, Al-Sayed AA, Bin Mani MI, Marzouki HZ. Epistaxis: What do people know and what do they do? Glob J Otolaryngol 2018;13:1-7.  Back to cited text no. 15
Mugwe P, Kamau KJ, Nyambaka OK. Knowledge, attitude and practice in first aid management of epistaxis by accident and emergency clinical staff at Kenyatta National Hospital. East Cent Afr J Surg 2014;19:17-21.  Back to cited text no. 16
Haymes AT, Harries V. 'How to stop a nosebleed': An assessment of the quality of epistaxis treatment advice on YouTube. J Laryngol Otol 2016;130:749-54.  Back to cited text no. 17
Middleton PM. Epistaxis. Emerg Med Australas 2004;16:428-40.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3], [Table 4]

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