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Clinical Procedures > Otolaryngologic and Dental Procedures
Nasal Pack - Anterior Epistaxis
Article Last Updated: Jul 11, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 14  
Author: Scott Bailey, MD, Staff Physician, Department of Emergency Medicine, UCLA Medical Center
Scott Bailey is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Phi Beta Kappa, and Society for Academic Emergency Medicine
Editors: Prajoy Kadkade, MD, Assistant Professor of Surgery, Division of Otolaryngology/Head & Neck Surgery, Department of Surgery, State University of New York at Stony Brook Medical Center and affiliated Northport Veterans Affairs Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, Pharmacy Editor, University of Nebraska Medical Center College of Pharmacy, eMedicine.com, Inc; Luis Michael Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA, Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Gil Z Shlamovitz, MD, Department of Emergency Medicine, David Geffen School of Medicine, UCLA Medical Center; Rick Kulkarni, MD, Assistant Professor of Medicine, Department of Emergency Medicine, David Geffen UCLA School of Medicine; Director of Informatics, UCLA/Olive View-UCLA Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
epistaxis, anterior epistaxis, posterior epistaxis, nosebleed, nasal pack, nasal fracture, cautery, cauterize, nasal packing, Merocel, Rapid Rhino anterior balloon tampon, nasal tampon, gauze packing, ribbon gauze, Kiesselbach’s plexus, nasal trauma, desiccation, epiphora, hypoxia, unilateral nosebleed, nose bleed
Ninety percent of epistaxes are anterior, originating from the Kiesselbach plexus (see Nasal vascular anatomy diagram below). Anterior epistaxes exhibit unilateral, steady, non-massive bleeding. Ten percent of epistaxes are posterior, exhibiting massive bleeding that is initially bilateral. Identifying the source of bleeding is important. Ask the patient from which side the bleeding occurred initially. Patients frequently report bilateral bleeding after assuming a recumbent position that allows blood to make a U-turn around the posterior aspect of the septum. Anterior epistaxis is most common in the child and young adult, while posterior epistaxis is more common in the older, hypertensive atherosclerotic patient. Even in elderly patients, anterior epistaxis is the most common type overall.
Nasal vascular anatomy.
Nasal vascular anatomy. Epistaxis has a wide variety of causes. Some of the most common causes of anterior epistaxis include mucosal breakdown caused by desiccation from forced air heating or inhaled medications; mucosal breakdown caused by infiltration by malignancy or granulomatous disease; and nasal trauma, including epistaxis digitorum.
Before attempting to control an epistaxis, assess patient stability, beginning with the ABCs. Determine whether the epistaxis was caused by trauma sufficient to create concern for oropharyngeal airway patency, intracranial injury, or stability of the c-spine. Assess underlying systemic comorbidities that might decrease the likelihood of success of hemostatic control procedures, such as bleeding diathesis or anti-platelet agent use. This assessment is particularly important in older patients. If the patient is stable, the intervention may be uncomplicated.
Nasal packing is the placement of an intranasal device that applies constant local pressure to the nasal septum. Some clinicians use nasal packing as a first-line treatment for epistaxis. If external pressure and cautery fail to control an anterior epistaxis, anterior nasal packing is required.
- Nasal pack is indicated in the presence of overt or suspected epistaxis.
- Nasal pack may be indicated in the presence of hematemesis or melena, as posterior epistaxis can present as hematemesis or melena.
- Patients with respiratory compromise may first require airway control and mechanical ventilation.
- Patients with hemodynamic compromise may first require volume and blood product resuscitation.
Topical anesthetics: Lidocaine (2% or 4% solution)
Topical nasal vasoconstrictors - Phenylephrine (Neo-Synephrine Fast-Acting Nasal)
- Oxymetazoline (Afrin, Neo-Synephrine 12-hour Maximum Strength Nasal)
- Epinephrine
Mixture of anesthetic and vasoconstrictor
- Phenylephrine plus lidocaine
- Epinephrine (0.25 mL of 1:1000 solution [ie, 0.25 mg]) plus lidocaine (20 mL 2% [ie, 400 mg])
Lidocaine 2%.
Epinephrine 1:1000.
- Gloves
- Eye shield
- Procedure lighting (best to use a headlamp)
- Tape
- Cotton
- Tongue depressors
- Commercially produced nasal tampon
- Gelfoam (absorbable gelatin)
- Surgicel (oxidized cellulose)
- Topical vasoconstrictors and anesthetics
- Nasal speculum
- Suction apparatus (Frazier suction tip)
- Silver nitrate cautery sticks
- Epistaxis tray (comprises much of above at some institutions)
Epistaxis tray.
Frazier suction tip.
Bayonet forceps.
Silver nitrate sticks.
Merocel nasal packing with airway, 8 cm.
Rapid Rhino anterior balloon tampon.
Smaller Merocel epistaxis pack.
Place the patient in the upright, not recumbent, position unless hemodynamic instability prevents it.
Patient sitting in an inappropriate, reclined position.
Patient sitting in an appropriate, upright position.
- Apply anterior nasal pressure to the cartilaginous part of the nose for 20 minutes. If this maneuver does not control the bleeding, a more invasive approach is required.
Anterior nasal pressure with joined tongue depressors.
- Assemble equipment and put on gown, goggles, and gloves.
- Keep patient in upright or minimally reclined position.
- Apply topical vasoconstrictor and anesthetic.
- Soak cotton ball in mix of 2% lidocaine + 1:1000 epinephrine.
- Put 1-2 cotton balls into the bleeding nostril (both nostrils if bleeding is not clearly unilateral).
- Place a dry cotton ball at the external nares to prevent leakage and dripping.
- Leave cotton balls in place for 10 minutes.
- If these anesthetic supplies are unavailable, a commercially-produced topical nasal decongestant may be quickly inhaled; then place cotton balls and apply anterior nasal pressure.
- Evacuate clots and collect blood.
- Remove cotton balls.
- To evacuate clots, use suction or have patient blow gently.
- Previously-accumulated blood will come out in a gush and then stop.
- Ongoing bleeding will appear as steadily dripping, bright red blood.
- Identify the bleeding vessel.
- Visualize the septum using the nasal speculum, stabilizing your hand on the patient's face.
- Examine the Kiesselbach plexus for bleeders.
- If the offending vessel has stopped bleeding, it appears as a red dot on the mucosa that may have a small amount of clot on it. If the vessel is still bleeding, active oozing is visible.
- Cauterize the wound.
- A clear view of the bleeding source is mandatory for the use of cautery methods.
- Cauterize to cease unilateral septal bleeding only. Bilateral cautery, both chemical and electrical, leads to increased risk of septal perforation.
- Chemical cautery
- Apply silver nitrate stick to red dot or oozing vessel for 5-10 seconds and then roll over the surrounding area (1 cm) for 5-10 seconds to cauterize feeding vessels.
- Apply antibiotic ointment over cauterized area. This provides prophylaxis against infection as well as a topical barrier to prevent desiccation and restart of bleeding.
- Electrical cautery
- This method is typically used by an otolaryngologist in the context of endoscopic visualization.
- Nasal packing
- If external pressure and cautery fail to control anterior bleeding, anterior nasal packing is required. Some clinicians use this as the first-line approach. The goal is to place an intranasal device that applies constant local pressure to the nasal septum. Traditional gauze packing is sufficient if prefabricated nasal tampons like Rapid Rhino or Merocel are not available (see Equipment).
- Commercial products packing technique
- Apply anesthetic to nasal mucosa with cotton or via inhalation.
- Apply surgical lubricant to the tampon.
- Gently insert the tampon to maximum achievable depth.
- Insert the tampon almost horizontally, along the floor of the nasal cavity.
- Merocel nasal tampon
Merocel nasal packing with airway, 8 cm.
Smaller Merocel epistaxis pack.
- This nasal tampon is made of polyvinyl alcohol, which is a compressed foam polymer that is inserted into the nose and expanded by application of water.
- The nasal tampon swells and fills the nasal cavity and applies pressure over the bleeding point.
- The Merocel tampon is believed to aggregate clotting factors to reach a critical level, thereby promoting coagulation.
- The Merocel success rate is 85% (equal to that of traditional ribbon gauze).
- Rapid Rhino anterior balloon tampon
Rapid Rhino anterior balloon tampon.
- This tampon is made of carboxymethylcellulose, a hydrocolloid material.
- It acts as a platelet aggregator and also forms a lubricant upon contact with water.
- Unlike Merocel, the Rapid Rhino balloon has a cuff that is inflated by air.
- The hydrocolloid or Gel-Knit reportedly preserves the newly-formed clot during tampon removal.
- Traditional gauze packing
Nasal packing with bayonet forceps and ribbon gauze.
- Apply anesthetic to nasal mucosa with cotton or via inhalation.
- Prepare ribbon gauze impregnated with petrolatum jelly and pack it anterior to posterior.
- Use bayonet forceps and a nasal speculum to place the gauze in a layered, accordion fashion.
- The gauze should be placed as far posteriorly as is possible.
- Failed anterior nasal packing
- If anterior packing failed to stop a confirmed and visualized anterior bleeding source, consider bilateral packing to increase the pressure on the nasal septum.
- If the anterior bleeding source was unconfirmed and bleeding continues, suspect posterior bleeding.
- All patients treated with nasal packing need to be prescribed an anti-staphylococcal antibiotic as prophylaxis against sinusitis and staphylococcal toxic shock syndrome.
- Patients should be given a follow-up appointment for removal of the packing in 72-96 hours.
- Patients who were cauterized only (and did not receive nasal packing) should gently apply antibiotic ointment to the cauterized area daily for 1 week and use a humidifier while sleeping.
- Instruct the patient to maintain upright posture for 48 hours (including sleep hours) and avoid laughter or heavy lifting for 24 hours. The goal is the reduction of intracranial venous blood pressure to minimize the likelihood of re-bleeding.
- Hemorrhagic shock
- Septic shock
- Pneumocephalus
- Sinusitis
- Septal pressure necrosis
- Neurogenic syncope during packing
- Epiphora (from blockage of the lacrimal duct)
- Hypoxia (from impaired nasal air movement)
- Staphylococcal toxic shock syndrome
- Failure to control bleeding
- ENT consultation is necessary.
- Advanced hemostatic measures may be necessary.
- Arterial embolization
- Arterial ligation (internal maxillary, sphenopalatine)
- Nasal septal dermoplasty
- Laser ablation
- Aminocaproic acid for bleeding diatheses such as hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome)
American College of Emergency Physicians
1125 Executive Cir
Irving, TX 75038-2522
800-798-1822
Columbia University Department of Otolaryngology/Head and Neck Surgery: Treatments for Nosebleeds
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Anterior nasal pressure with joined tongue depressors. |
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Nasal packing with bayonet forceps and ribbon gauze. |
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Patient sitting in an inappropriate, reclined position. |
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Patient sitting in an appropriate, upright position. |
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- Frazee TA, Hauser MS. Nonsurgical management of epistaxis. J Oral Maxillofac Surg. Apr 2000;58(4):419-24. [Medline].
- Nasal emergencies and sinusitis. In: Tintinalli JE, Ruiz E, Krome RL. Emergency Medicine: A comprehensive study guide. 4th. New York: McGraw-Hill, Health Professions Division; 1996:1083-93.
- Saba HI, Morelli GA, Logrono LA. Brief report: treatment of bleeding in hereditary hemorrhagic telangiectasia with aminocaproic acid. N Engl J Med. Jun 23 1994;330(25):1789-90. [Medline].
- Schaitkin B, Strauss M, Houck JR. Epistaxis: medical versus surgical therapy: a comparison of efficacy, complications, and economic considerations. Laryngoscope. Dec 1987;97(12):1392-6. [Medline].
Nasal Pack - Anterior Epistaxis excerpt Article Last Updated: Jul 11, 2006
Topic originally published: Jul 10, 2006
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