Epistaxis Management

Epistaxis Opener.jpeg

This module describes how to

that does not resolve with direct pressure.


  1. Epistaxis that does not resolve after 15 minutes


  1. Significant facial trauma—consult otolaryngology

  2. Haemodynamic instability

  3. Cautery is contraindicated if the source of bleeding cannot be seen


Always verify your patient’s identity and obtain informed consent before proceeding.

How do I explain this procedure?

“I’m going to try different ways to stop your nose bleeding.”

What can my patient expect?

“We will first try to stop the bleeding by pinching your nose for 15 minutes. If it doesn’t work, I will try to find the bleed and stop it with a chemical. This will be uncomfortable, but it will not burn you. If I can’t stop the bleed this way, I will need to pack your nose tightly with gauze and perhaps even a small balloon. This will be very uncomfortable for you, but this kind of bleed must be stopped. You may need to stay in hospital overnight.”

What is my patient’s role?

“Tell me if you have any allergies, take blood thinners, or have

. Let me know if you have severe pain or dizziness at any point.”


Prepare a trolley with equipment.

Epistaxis Equipment 1.png

Documentation

  1. Patient notes

Equipment

  1. Non-sterile gloves

  2. Alcohol-based hand rub

  3. Emesis basin

  4. Linen saver

  5. Two tongue depressors

  6. Adhesive tape

  7. Nasal speculum if available

  8. Good light source

  9. Silver nitrate sticks

  10. 1-2% lignocaine with adrenaline

  11. Cotton balls

  12. Gauze strip (1.5 m per nostril), preferably in

  13. Forceps, preferably Bayonet forceps

  14. Foley catheter

  15. 10 ml syringe

  16. 10 ml sterile water

  17. if available

  18. Gauze


Position the patient sitting upright.

Most epistaxis originates in the anterior nasal cavity, and most anterior epistaxis originates from Kiesselbach’s plexus.

Epistaxis Site.jpeg


Follow medical asepsis with non-sterile gloves.

  1. Perform hand hygiene and don non-sterile gloves.

  2. If not done yet, ask the patient to sit forward and pinch the cartilaginous part of their nostrils for 15 minutes. Alternatively, tape two tongue depressors together in the middle to create a nose clip and apply it for 15 minutes.

  3. If the bleeding continues, place the emesis basin and linen saver in the patient’s lap to catch blood. Ask the patient to gently blow their nose to remove clots to identify the source of the bleed.

  4. Inspect the nasal passages with a light and nasal speculum, and the oropharynx for blood running down the throat.

  5. Insert cotton soaked in

    into the affected nostril for 5-10 minutes, then remove.

  6. Inspect the nostril once more. If still bleeding actively and a source is visible, use silver nitrate to cauterise a small area on and around the bleeding point. Roll the stick over the area for up to 5 seconds. Do not cauterise blindly or widely. Only ever cauterise one side of the

  7. If bleeding actively with no visible source or if silver nitrate failed, place an anterior pack.

  8. Anterior pack: Use Bayonet forceps to insert the gauze strip horizontally along the floor of the nose to the back of the nose. Withdraw and grip the gauze strip 7-10 cm from the tip of the nose and insert it again. Continue inserting folds of gauze until the anterior nose is fully packed (± 1.5 m per nostril). Leave a short end outside the nose.

    Epistaxis Procedure.jpeg

  9. If you have access to Rapid Rhino, it is a much easier and less traumatic device to use for epistaxis. Wet it to create a lubricant for insertion and insert along the floor of the nose. Inflate with 7-8 ml of air and then add titrations of 0.5-1 ml at a time to tamponade the bleeding. It will require ongoing titration every few hours, of 0.5-1 ml, as the air diffuses out of the

  10. Observe the patient for

    .

  11. Dispose of medical waste safely.

  12. Record completion of the procedure in patient notes.

  13. Patients with a pack need to be admitted for observation and removal after 48 hours. Continued bleeding warrants otolaryngology referral.


The patient is uncooperative.

Try to reassure the patient, and explain why this is necessary. You may need an assistant to help with restraining.

I don’t have access to a Rapid Rhino and the patient is still bleeding.

Remove the anterior pack. Place a

by feeding a Foley catheter through the nostril until it is visible in the oropharynx. To avoid gagging, advance no further. Inflate the balloon with 5 ml of water, then retract it until it is firmly wedged in the posterior nose. Inflate with another 5 ml water. Wrap the catheter in gauze where it exits the nose and secure it to the face with tape. Subsequently, place an anterior pack.

Epistaxis Troubleshooting.jpeg


  1. Failure to stop bleeding; haemodynamic instability

  2. Airway compromise

  3. Nasal abrasions

  4. Pressure necrosis and septal perforation

  5. Sinusitis and toxic shock syndrome

  6. Splash injury to healthcare personnel

  7. Rebleeding on pack removal


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

  2. Womack JP, Kropa J, Jimenez Stabile M. Epistaxis: Outpatient Management. Am Fam Physician. 2018;98(4):240-245.

  3. Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgraduate Medical Journal. 2005;81:309-314.