Step 3B: Posterior Bleed
- Attempt direct pressure (internal or external)
- Topical vasoconstrictor agents
- Oxymetazoline or Phenylephrine
- 2% lidocaine with epinephrine
- Topical pro-coagulant agents (TXA or topical thrombin)
- Posterior Nasal Packing
- Intravenous TXA
Step 4 : Uncontrolled Bleeding
- Intravenous TXA
- Consider reversal of anticoagulants
- Consult Interventional Radiology or Interventional Neurology for angiography and embolization
Disposition
Discharge if vitals stable, bleeding controlled after 4hr observation
- Consider walking patient
- ENT follow up in 2-3 days if nasal packing applied
Admit if
- Bilateral nasal packing (place on telemetry)
- Bleeding uncontrolled
- Transfusion required
- Significant comorbidities increasing mortality risk
Pro-Coagulant Dosing
- Topical Thrombin – 5000IU (topical only)
- Topical TXA – 500mg in 5mL (soak in packing)
- Intravenous TXA – 10mg/kg bolus
Special Points:
- No antibiotics needed for anterior or posterior packing
- When inflating a Rapid-Rhino use normal saline or sterile water
- Allowing the patient to suck ice cubes has been shown to decrease blood flow to the nose
References
Barnes ML, Spielmann PM, White PS. Epistaxis: a contemporary evidence based approach. Otolaryngol Clin North Am. 2012;45(5):1005-17.
Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013;31(9):1389-92.
Zahed R, Mousavi jazayeri MH, Naderi A, Naderpour Z, Saeedi M. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med. 2018;25(3):261-266.
Murano T, Brucato-duncan D, Ramdin C, Keller S. Prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the ED. Am J Emerg Med. 2019;37(4):726-729.
Biswas D, Mal RK. Are systemic prophylactic antibiotics indicated with anterior nasal packing for spontaneous epistaxis?. Acta Otolaryngol. 2009;129(2):179-81.
Step 2: Patient Evaluation
- Have patient blow their nose/clear nasal passages of clot, consider suctioning if needed
- Identify if bleeding site anterior or posterior (inspect nares, turbinates and oropharynx)
Step 3A : Anterior Bleed
- Attempt direct pressure (internal or external)
- Topical vasoconstrictor agents
- Oxymetazoline or Phenylephrine
- 2% lidocaine with epinephrine
- If able to identify bleeding site:
- Silver nitrate (around, then over bleeding site)
- Electrocautery to bleeding site
- Topical pro-coagulant agents
- TXA, topical thrombin, surgicel
- Anterior Nasal Packing
- Uncontrolled epistaxis seen in the Emergency Room
- None
Step 1: Initial Evaluation
- Obtain H&P including duration, trauma, use of blood thinners, therapies tried, prior history of bleeds, comorbidities
- Have patient lean forward, protect airway
- Obtain IV access, check CBC, INR (if on warfarin), consider NS/LR bolus
- If Severe bleeding start with posterior nasal packing