Amy Patel, PA-C
Epistaxis is a hemorrhage or bleeding coming from the nose. Epistaxis is commonly seen in primary care, urgent care, and also emergency department settings. Fortunately, most cases are spontaneous, benign, and self-limiting. However, approximately 6% of nosebleeds require a higher level of care and it is imperative to understand the treatment options available. To better understand treatment options, it is essential to first divide epistaxis into two categories based on anatomy. Likewise, epistaxis can be classified as anterior or posterior.
Anterior Bleeds vs Posterior Bleeds
Anterior epistaxis account for nearly 90% of all nosebleeds. These bleeds usually originate from Kiesselbach’s plexus. This venous plexus is located in the anteromedial nostril. It is composed of branches from 3 separate arteries:
- Anterior Ethmoidal artery
- Sphenopalatine artery
- Superior labial branch of the facial artery.
Posterior epistaxis originates from the sphenopalatine artery. Posterior bleeds, although more rare than anterior, are far more dangerous and can be life threatening. Hemostasis of these bleeds requires ED intervention also with possible ENT consultation and admission for close monitoring.
Approach to Treatment
Patients with massive hemorrhage and shock should be treated in the emergency department. This setting ensures that airway and other critical interventions are readily available. Treat patients who are hemodynamically stable in a stepwise fashion:
Pinch the nose
Have the patient blow and clean their nose and then use 2 sprays of Oxymetazoline into nasal passage. Pinch the alae tightly and continuously for 15 minutes. Have the patient also lean forward and bend at the waist to prevent blood from going down the throat.
Clean nasal passages
If your patient is unable to clear nasal passages on their own, it may also be necessary to use gentle suction to clear the nasal passages.
Depending on your site of work, different options for analgesia may be available. Options include 2% lidocaine, lidocaine with epinephrine, also also 4% cocaine. Soak cotton swab or pledgets with agent and place into the cavity using bayonet forceps.
Locate bleeding site
Using a nasal speculum, move in a superior-inferior plane to avoid injuring the septum. Make sure the patient does not hyperextend the neck, which will block adequate view into the nasal cavity.
Anterior Epistaxis Treatment Options
If conservative treatment including vasoconstrictive agents and pressure fail, you still have multiple other options that you may consider for hemostasis.
If the source of bleeding can be seen, cautery is also an option. Suction and briefly dry the area prior to cauterization. Silver nitrate sticks work well for chemical cauterization. They should only be used unilaterally and also in a rolling motion over the area of the vessel. Do not apply too much pressure and do not use generally throughout a large area. Doing so may cause too much interference with blood flow inferiorly and may result in ulcers. If used bilaterally across the septum, complications such as septal perforations may occur and thus bilateral use should be
Electrical cautery is also an option. The patient should be anesthetized prior to the procedure. Like chemical cautery, use is also limited if the surface is not adequately dry.
Several nasal packings are available if the above treatments are unsuccessful. Options include nasal tampons, nasal balloon catheters, vaseline gauze, and thrombogenic foams and gels.
- Nasal tampons (Merocel sponge): Pretreat patients with a vasoconstrictor/topic anesthetic. Coat the tampon with bacitracin and then insert along the floor of the nose. Expand Merocel with 10 ml of saline.
- Vaseline gauze packing: Use bayonet forceps with nasal speculum and layer gauze bottom to top like an accordion at the floor of the nose. This technique may also be more difficult in comparison to the others..
- Nasal balloon catheter (Rapid Rhino): Easiest method to control epistaxis of all nasal packings. Come in short and long for anterior and posterior bleeds. Soak in sterile water (not saline) for 30 seconds and insert along the floor of the nasal cavity and inflate with air.
- Gels/Foams: Apply these hemostatic materials directly over the bleed to achieve hemostasis.
Transexamic Acid (TXA)
Transexamic acid (TXA) is a topical antifibrinolytic agent. Soak gauze or merocel with TXA and apply topically. This is also a good option to help control bleeding In other places beside the nose.
Posterior Epistaxis Treatment Options
If your patient has continuous hemorrhage despite anterior packing, you are likely treating posterior epistaxis. Posterior bleeds may respond to topical vasoconstrictors but typically require balloon catheters to create tamponade. Options for posterior epistaxis treatment includes a long Rapid Rhino, balloon catheter, or also a foley catheter. Balloon catheters for posterior bleeds consist of two balloons: a smaller posterior for the nasopharynx and a larger anterior balloon for the nasal cavity. You can also use a 10 or 14 French Foley catheter if a balloon catheter is unavailable.
Posterior packings are more difficult and more painful than anterior packing and have a higher risk of
complications. Posterior bleeds may require ENT consultation or surgical intervention. These patients are typically hospitalized for close monitoring. Check the posterior oropharynx after packing to ensure that there is no persistent bleeding. Surgery should be performed if hemorrhage persists despite all interventions.
Epistaxis is a common issue in patients of all ages. Based on the intervention that is required, consider prophylactic antibiotics and ensure good follow up instructions for packing removal in 3-5 days. Also discuss sinus precautions with patients including avoiding blowing the nose, using saline nasal sprays to moisturize the nasal cavity, and avoiding lifting heavy objects.
Alter, H. (2021). Approach to the adult with epistaxis: UpToDate. Retrieved January 31, 2022, from
Diamond L. Managing epistaxis. JAAPA. 2014 Nov;27(11):35-9. doi: 10.1097/01.JAA.0000455643.58683.26. PMID: 25303882.
Seikaly, H. (2021). Epistaxis. The New England Journal of Medicine. 384(10), 944-951 DOI: 10.1056/NEJMcp2019344
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