Preparation

• Gloves
• Goggles
• Kidney basin
• Nasal or otoscope speculum
• Topical vasoconstrictor (e.g., Oxymetazoline)
• Lidocaine 2% with epinephrine
• Topical antibiotic ointment
• Ribbon gauze impregnated with petroleum jelly
• Bayonet forceps

Procedure Steps

Step 1: Health history and physical assessment

Posterior bleeds should be referred to hospital. Assess duration, severity, frequency, timing related to activities, precipitating or aggravating factors, and possibility for foreign body. History should assist in determining whether the cause of epistaxis is due to mechanical trauma, medication-related, or an underlying condition (e.g., hypertension).

Consider referral to otolaryngologist if child under 2 years of age or patient has underlying disorders that predispose to bleeding. Assess for conditions that increase the risk of bleeding:

• tumors
• coagulation disorders
• recent trauma or surgery
• medications

Physical assessment:

• vital signs
• mental status
• airway and hemodynamic stability
• examination of the nose with speculum and light source

Step 2: Initiate first-aid measures

Note: Consider beginning this step while getting the health history.

Position the patient upright with head tilted forward. Hyperextension of the neck facilitates drainage of blood to the posterior pharynx and increases the risk of aspiration or emesis. 

Apply firm pressure to soft cartilaginous aspect of nose for 10-15 minutes. Do not remove pressure to assess if bleeding has stopped until 10-15 minutes has passed.

Encourage patient to spit blood or clots from posterior pharynx into kidney basin to reduce risk of aspiration or emesis.

Step 3: Reassess for hemostasis

Step 4: Local vasoconstriction

May be done in conjunction with first-aid measures or if first-aid measures fail to achieve hemostasis alone.

Directly spray or soak a cotton ball in a local vasoconstrictor such as Oxymetazoline or phenylephrine. Leave in place for 10-15 minutes and reassess.

Step 5: Reassess for hemostasis

Step 6: Apply topical anesthesia to nasal cavity

Consider this step prior to examination of the nose as active bleeding obscures visualization. Soak cotton balls in lidocaine 2% with epinephrine. Insert soaked cotton balls into bleeding nostril and leave for 10 minutes. Upon removal, have patient gently blow nose to remove clots.

Step 7: Nasal cautery

Do not perform nasal cautery if the bleed site cannot  be identified.

Silver nitrate reacts to the mucosal lining to produce local chemical damage. Adequate anesthesia and vasoconstriction is required prior to cauterization (see Step 6).

•Apply firm pressure with silver nitrate stick to site of bleed for 5-10 seconds.
•Roll the tip of the silver nitrate stick on surrounding mucosa until dark gray eschar is formed (to cauterize feeding vessels).
•Remove excess silver nitrate to prevent staining of skin.
•Cauterize only one side of septum at a time to prevent risk of perforation due to decreased vascularization of cartilage.
•Apply topical antibiotic ointment to cauterized area for prophylaxis against infection and acts as topical barrier to prevent restart of bleeding.

Step 8: Reassess for hemostasis

Step 9: Anterior nasal packing

Constant flow of blood in the posterior pharynx after packing suggests a posterior bleed.

Perform anterior nasal packing if direct external pressure and nasal cautery are unsuccessful to achieve hemostasis  or if no obvious bleed site is visualized . Adequate anesthesia and vasoconstriction required prior to nasal packing (see Step 6).

Use traditional gauze packing or commercially available nasal sponges or tampons (e.g., Rapid Rhino or Merocel – follow manufacturers instructions for use of commercially prepared products). Packing with gauze – use ribbon gauze impregnated with petroleum jelly. Use the Bayonet forceps to layer the ribbon gauze from bottom to top. Insert packing as posteriorly as possible.

Risks of nasal packing: failure to stop bleeding; toxic shock syndrome; blockage of nasal airway, sinus drainage or nasolacrimal duct; dislodgement of packing to oropharynx; nasovagal reflex (hypotension, bradycardia).

Examine the posterior pharynx after packing inserted. Some blood behind the uvula is normal, and should be expected to stop. If continued bleeding occurs, this suggests a posterior bleed and referral is warranted.

Aftercare

• Review simple first-aid measures with patient; seek care if bleeding has not stopped after 20 min of first aid measures.
• Review common causes of epistaxis.
• Avoid blowing or picking nose.
• Refrain from heavy lifting or strenuous activity for 1-2 weeks with no evidence of bleeding.
• Use humidifier or nasal saline spray.
• Avoid smoking.
• Sneeze with mouth open.
• Apply topical antibiotic cream or petroleum jelly to nares.
• If packing is in place, do not remove packing.

Patient Education

Follow-up

• Consider referral to otolaryngologist if the patient is under 2 years of age or has underlying disorders that predispose them to bleeding.
• Severe or prolonged epistaxis should have referral to ENT to rule out tumour in nasal cavity.
• Arrange for nasal packing to removed in 2-3 days by ENT.
• Consider lab investigation in presence of recurrent, or persistent heavy epistaxis (CBC, PT/INR, aPTT).
• Educate patient to monitor for fever, bleeding that continues or breaks through packing, severe pain, nausea, or vomiting and to seek immediate care.

Key Takeaways

• Epistaxis is a common condition and most cases can be managed with simple first aid measures.
• Assess ABCs when patient presents with epistaxis.
• 90% of epistaxis arise from the anterior nasal septum.
• A stepwise approach can be used to achieve hemostasis: first-aid measures, local vasoconstriction, nasal cautery, anterior nasal packing.
• Commercially available devices for nasal packing are quicker and easier to use than traditional ribbon gauze packing.
• Posterior bleeds should be referred to hospital for management.