Epistaxis Management Protocol

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Epistaxis Management Protocol

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


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


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

Inclusion Criteria
  • Uncontrolled epistaxis seen in the Emergency Room
Exclusion Criteria
  • 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

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