Contributor: Meghan Hurley, MD

Educational Pearls:

1. Initial Assessment

2. Start with a physical examination:

3. Determine if the bleed is anterior or posterior.

4. Perform a primary survey: assess airway, breathing, and circulation (ABCs).

5. Airway compromise = intubation immediately.

6. If the patient is stable, have them blow out any clots, then re-examine the nares.

7. Topical Medications

8. Anesthetics: provide local anesthesia and pain relief.

9. Lidocaine

10. Tetracaine

11. Vasoconstrictors: reduce bleeding.

12. LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides anesthesia and vasoconstriction.
13. Cocaine pledgets (less common).
14. Tranexamic acid (TXA).

15. Oxymetazoline (Afrin).

16. Cautery (Chemical): If an anterior bleed is visualized, silver nitrate can be applied for cauterization

17. Technique Tips

18. Use a nasal speculum.

19. Spread up and down rather than side to side to avoid injury to the septum.

20. Place LET-soaked gauze in the nares.

21. Apply a nasal clamp for ~15 minutes to compress the vessels.

22. Note that pledgets may cause upper lip numbness

23. Reassessment

24. After 15 minutes, remove materials and inspect for a source of bleeding.

25. If still bleeding and a source is identified, cauterize the site.

26. Observe for 15 minutes to monitor for recurrence of bleeding.

27. Packing

28. If the above measures fail to control bleeding:

29. Anterior packing:
30. Nasal tampon (Merocel)

31. Convenient for outpatient removal.

32. Balloon device

33. Inflate the anterior balloon for compression.

34. Posterior packing:

35. More complex, should consult ENT for additional assistance.

36. Disposition & Follow-Up

37. Although rare, toxic shock syndrome is a possible complication of nasal packing.

    • Antibiotic prophylaxis is controversial, but may be considered in high-risk patients.

    • Outpatient follow-up if stable:

    • Tampon: The patient can remove it at home.

    • Balloon: Return to ED for removal.

38. Risk Factors for Epistaxis & Prevention

39. Deviated septum, dry environments, and anticoagulant use

    • Advise on humidifier use, nasal saline, and medication review to minimize future episodes.

References:

1. Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery. 2020;162(1_suppl):S1-S38. doi:10.1177/0194599819890327

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4

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