Nasal bleeding that does not stop with a topical vasoconstrictor and direct pressure applied by the patient (described below in the “Technique” section).



   imagesAnterior source bleeding that can be visualized

imagesAnterior Nasal Packing

   imagesAnterior source bleeding that cannot be visualized

   imagesCauterization fails

imagesPosterior Nasal Packing or Balloon Tamponade

   imagesAnterior source cannot be identified and

      imagesBleeding from both nares or

      imagesBlood draining into the posterior pharynx

   imagesAnterior packing of both nares fails to control bleeding




imagesNasal packing can cause pain or discomfort

imagesRisk of infection, septal damage, and ulceration

imagesRisk of balloon migration, airway obstruction, or aspiration with posterior packing


imagesThe choice of procedure depends on the source of bleeding. The source can be identified by direct visualization, or with use of a nasal speculum (described in more detail in the “Technique” section).

imagesNosebleeds are most commonly anterior (80% to 90%), originating from the Kiesselbach plexus in the septum

imagesMost posterior nosebleeds originate from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx. A posterior source is likely when an anterior source cannot be identified, when bleeding is from both nares, or when blood is draining into the posterior pharynx.

imagesGeneral Basic Steps

   imagesPatient preparation




   imagesAnterior packing

   imagesPosterior packing


imagesPatient Preparation

   imagesAsk the patient to blow his or her nose, which decreases the effects of local fibrinolysis and removes clots (FIGURE 75.1)

   imagesAsk the patient to lean forward and apply continuous pressure to the alae of both nares for 10 to 20 minutes. If this stops bleeding, consider sending patient home with follow-up to ear, nose, and throat (ENT) specialist or Primary Medical Doctor (PMD).


   imagesApply a topical anesthetic and vasoconstrictor

      imagesSoak cotton or gauze in 2% lidocaine with or without topical epinephrine or 4% topical cocaine. Place in the nasal cavity for 15 to 20 minutes.

      imagesAlternatively, a topical anesthetic with a decongestant (2% lidocaine and 4% phenylephrine mixed 1:1) or oxymetazoline hydrochloride (Afrin) nasal spray may be used

   imagesBecause patients may be apprehensive and packing is uncomfortable, opiates or benzodiazepines may be given before the examination (strongly recommended in cases of posterior packing)


   imagesPosition the patient sitting upright, facing forward in the sniffing position

   imagesInsert a nasal speculum so that one blade moves superiorly and the other inferiorly and spread the nares vertically. Suction all remaining clots and blood. This permits visualization of most anterior sources.


   imagesIf an anterior source is visualized, cauterization should be attempted. To be effective, cautery should be performed after bleeding is controlled. Only cauterize one side of the septum at a time to prevent perforation or necrosis of the septum.

   imagesChemical cauterization can be performed using silver nitrate sticks. Apply the tip of a silver nitrate stick to the bleeding site until a white precipitate forms (usually a few seconds, rarely more than 10).

   imagesIf bleeding is vigorous, electrocauterization can be used. Apply the device to the bleeding site for up to 10 seconds or until a white precipitate forms.


FIGURE 75.1 Anatomy of nasal septum. (From Kost SI, Post JC. Management of epistaxis. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:663, with permission.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Epistaxis
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