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Epistaxis – Spoon Feed Version

April 27, 2021

Written by Clay Smith

Spoon Feed
This is a review of epistaxis with a simplified algorithm as a bonus at the end.

Why does this matter?
Epistaxis is common: 1/200 ED visits. Most cases are simple enough to manage at home with direct pressure. The author presents an algorithm for management ranging from mild bleeding to torrential flow and more invasive techniques.

Friendly advice – wear eye protection…

Anatomy & Evaluation

  • It may be due to dry air, inflammation, intranasal medication, blood dyscrasia, or underlying disease like hereditary hemorrhagic telangiectasia.

  • Most bleeds, 80-90%, are anterior arising from the Kiesselbach plexus.

  • Posterior bleeds arise from branches of the sphenopalatine and ascending pharyngeal arteries and are often heavier and harder to control. They also increase risk of aspiration or airway compromise.

  • Always wear PPE. Do a thorough history and exam.


  • Direct pressure – 15-20 minutes over the lower third of the nose, leaning forward is best. Perform anterior rhinoscopy after direct pressure to determine if there is a discrete site of bleeding.

  • Topical vasoconstrictors – If you see the bleeding on rhinoscopy, agents like oxymetazoline, phenylephrine, epinephrine, or cocaine are an option. They don’t raise MAP. Personally, I will try these agents even if I can’t see an obvious source.

  • TXA – There is moderate quality evidence for oral or topical TXA in reducing recurrent bleeding. JF covered TXA for epistaxis when taking antiplatelet agents. Also, TXA was compared with packing, and was as good and seemed to reduce short-term rebleeding.

  • Cautery – If a bleeding area is seen, cautery is very effective. Electrocautery seems more effective than chemical (failure in 14.5% electrocautery vs. 35.1% with silver nitrate). Avoid cautery of both sides of the nasal septum to reduce risk of septal perforation.

  • Anterior packing – The author recommends anterior packing after direct pressure if not hemostatic and you can’t see the source on rhinoscopy or if still bleeding profusely, obscuring the ability to see. If you can see the source but topical agents and cautery have failed, anterior packing is the next step.

    • Resorbable – slightly less painful than non-resorbable; all are effective and minimize trauma from removal; more expensive.

      • Floseal is gelatin + bovine thrombin

      • Quixil is a fibrin sealant made of human cryoprecipitate + thrombin

      • Nasopore is freeze-dried polyurethane foam.

    • Non-resorbable – usually more painful on insertion; left in place 48-72 hours.

      • Merocel – expandable polyvinyl acetate tampon

      • Rapid Rhino – fabric sponge coated with carboxymethylcellulose (maybe a bit less painful than Merocel).

  • Salvage bleeding control

    • Posterior packing – with gauze or balloon tamponade; very painful and fraught with complications: “otitis media, sinusitis, necrosis of nasal tissues, airway obstruction, hypoxemia due to stimulation of the nasopulmonary reflex, and toxic shock syndrome.”

    • Ligation/embolization – This is a final step in refractory cases. Both are effective. Ligation may be more cost effective than embolization.

  • What about anticoagulation or antiplatelet agents? Stop taking these agents during active bleeding. Reversal may be indicated in severe posterior bleeds.

  • What about antibiotics for packing? – This is an area of controversy. But it is likely unnecessary. We covered this single study, and there are meta-analyses that confirm this.

  • What about hypertension? ENT often seems to blame epistaxis on HTN. There is association but unlikely causation. And it’s anyone’s guess as to how to manage BP during epistaxis.

Simplified algorithm

  1. Direct pressure 15-20 minutes, then rhinoscopy
    Hemostasis = done. If still bleeding, go to step 2.
    Comment: Ensure a “no peeking” policy with continuous direct pressure.

  2. Source visible = topicals or cautery. Not visible or still profuse = anterior packing; go to step 3.
    Comment: Suction or have the patient gently blow out large clots. I would use oxymetazoline first, then topical TXA if that fails (atomized 500 mg diluted in 5 mL normal saline solution sprayed into both nostrils). Silver nitrate is easy to use, but the field needs to be almost bloodless for it to work. Use suction to dry things up. Be very careful with this! It hurts. Use topical anesthetic if you can.

  3. Topicals/cautery fails = anterior packing
    Comment: Resorbable is better if you have it. If non-resorbable, I would go with the Rapid Rhino.

  4. Anterior packing fails = call ENT. Consider posterior packing. Consider ligation/embolization (if you are an otolaryngologist).
    Comment: The Epistat has a posterior balloon. It’s a big deal if you’re at this point. This may be obvious, but if posterior and this hard to stop, the patient will need admission.

  5. Posterior and Severe (needs transfusion or hemodynamically unstable) – stop anticoagulants/antiplatelet agents; strongly consider reversal agents.

Epistaxis. N Engl J Med. 2021 Mar 11;384(10):944-951. doi: 10.1056/NEJMcp2019344.

One thought on “Epistaxis – Spoon Feed Version

  • Love the spoonfeed!
    A comment and question:
    1. I have patients blow their nose to evacuate clots first, as soon as they arrive, before applying 15-20 mins of pressure. If they blow after, sometimes the bleeding starts again and you have to hold pressure for 15-20 mins again.
    2. Question- if you get hemostasis after pressure alone, and see the likely source area, do you cauterize that area if it’s not still bleeding? I was taught to do that to seal it off and prevent more bleeding later, but sometimes touching that area with the silver nitrate stick makes it start up again.

What are your thoughts?