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Home > Emergency Medical Minute > Episode 982: Epistaxis Management
Podcast: Emergency Medical Minute
Episode:

Episode 982: Epistaxis Management
Category: Science & Medicine
Duration: 00:06:23
Publish Date: 2025-11-10 11:00:00
Description:

Contributor: Meghan Hurley, MD

Educational Pearls:

1. Initial Assessment

  • Start with a physical examination:

    • Determine if the bleed is anterior or posterior.

  • Perform a primary survey: assess airway, breathing, and circulation (ABCs).

    • Airway compromise = intubation immediately.

  • If the patient is stable, have them blow out any clots, then re-examine the nares.

2. Topical Medications

  • Anesthetics: provide local anesthesia and pain relief.

    • Lidocaine

    • Tetracaine

  • Vasoconstrictors: reduce bleeding.

    • LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides anesthesia and vasoconstriction.

    • Cocaine pledgets (less common).

    • Tranexamic acid (TXA).

    • Oxymetazoline (Afrin).

  • Cautery (Chemical): If an anterior bleed is visualized, silver nitrate can be applied for cauterization

3. Technique Tips

  • Use a nasal speculum.

    • Spread up and down rather than side to side to avoid injury to the septum.

  • Place LET-soaked gauze in the nares.

  • Apply a nasal clamp for ~15 minutes to compress the vessels.

  • Note that pledgets may cause upper lip numbness

4. Reassessment

  • After 15 minutes, remove materials and inspect for a source of bleeding.

  • If still bleeding and a source is identified, cauterize the site.

  • Observe for 15 minutes to monitor for recurrence of bleeding.

5. Packing

  • If the above measures fail to control bleeding:

    • Anterior packing:

      • Nasal tampon (Merocel)

        • Convenient for outpatient removal.

      • Balloon device

        • Inflate the anterior balloon for compression.

    • Posterior packing:

      • More complex, should consult ENT for additional assistance.

6. Disposition & Follow-Up

  • Although rare, toxic shock syndrome is a possible complication of nasal packing.

    • Antibiotic prophylaxis is controversial, but may be considered in high-risk patients.

  • Outpatient follow-up if stable:

    • Tampon: The patient can remove it at home.

    • Balloon: Return to ED for removal.

7. Risk Factors for Epistaxis & Prevention

  • Deviated septum, dry environments, and anticoagulant use

    • Advise on humidifier use, nasal saline, and medication review to minimize future episodes.

References:

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

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4

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