Epistaxis is a common problem in the emergency department (ED). Generally, it is relatively benign, but it can sometimes produce serious, life-threatening situations. Up to 60% of the population is estimated to have had at least 1 episode of epistaxis at some point in their lives. Of this group, 6% seek medical care to treat epistaxis, with 1.6 in 10,000 requiring hospitalization. 
Most cases of epistaxis occur in children younger than 10 years. Epistaxis is more common in colder seasons and in northern climates because of decreased humidity and the consequent drying of the nasal mucosa.  Other major etiologies include inhaled medications, mucosal breakdown caused by infiltration by malignancy or granulomatous disease, and nasal trauma.
Ninety percent of epistaxes are anterior, originating from the Kiesselbach plexus (see the image below). Anterior epistaxes exhibit unilateral, steady, nonmassive bleeding. Just 10% of epistaxes are posterior, exhibiting massive bleeding that is initially bilateral.
Nasal vascular anatomy
The lateral nasal wall is supplied by the sphenopalatine artery posteroinferiorly and by the anterior and posterior ethmoid arteries superiorly. The nasal septum also derives its blood supply from the sphenopalatine and the anterior and posterior ethmoid arteries with the added contribution of the superior labial artery (anteriorly) and the greater palatine artery (posteriorly). The Kiesselbach plexus, or the Little area, represents a region in the anteroinferior third of the nasal septum, where all 3 of the chief blood supplies to the internal nose converge. For more information about the relevant anatomy, see Nasal Anatomy.
A focused history aids the clinician in managing the acutely bleeding patient. This history should include some or all of the following questions:
Which side is bleeding?
Which side was bleeding initially?
What is the estimated amount of blood loss?
Is it recurrent?
Is it in the pharynx?
Has any trauma recently occurred?
Are symptoms of hypovolemia present?
What are the patient's past medical history and current medications (eg, aspirin, warfarin)? 
As with any unstable patient, initial management begins by assessing airway, breathing, and circulation (the ABCs). Next, the source of the bleeding should be identified. The source of most anterior bleeds can be identified using a headlight and adequate suction.
Once the bleeding point is identified, cauterization—either chemical (silver nitrate) or electrical (hotwire or bipolar cautery)—usually provides definitive treatment.  If cauterization is unsuccessful, anterior nasal packing is the next step.
Nasal packing is the placement of an intranasal device that applies constant local pressure to the nasal septum. Nasal packing works by (1) direct pressure; (2) consequent reduction of mucosal irritation, which decreases bleeding; and (3) clot formation surrounding the foreign body, which enhances pressure.
Anterior nasal packing is indicated for overt or suspected epistaxis after direct pressure, topical agents, or silver nitrate cauterization. It may be indicated in hematemesis or melena (either of which can be a presentation of posterior epistaxis).
Patients with respiratory compromise may first require airway control and mechanical ventilation. Patients with hemodynamic compromise may first require volume and blood product resuscitation.
Airway, breathing, and circulation (ABCs) take priority in the acute management of epistaxis. Less invasive approaches to controlling epistaxis should be attempted before anterior nasal packing is initiated. [5, 6, 7]
Go to Surgery for Pediatric Epistaxis for complete information on this topic.
Apply anterior nasal pressure to the cartilaginous part of the nose for 20 minutes (see the image below). If this maneuver does not control the bleeding, a more invasive approach is required.
Assemble equipment and put on gown, goggles, and gloves. A headlamp, if available, is helpful; its use enhances the visual field. Keep patient in an upright or minimally reclined position.
Topical Anesthesia and Vasoconstriction
Soak cotton balls in a mix of 2% lidocaine and 1:1000 epinephrine. Put 1-2 cotton balls into the bleeding nostril. (If bleeding is not clearly unilateral, put cotton balls into both nostrils.) Place a dry cotton ball at the external nares to prevent leakage and dripping. Leave the cotton balls in place for 10 minutes.
If these anesthetic supplies are unavailable, a commercially produced topical nasal decongestant may be quickly inhaled; then, place cotton balls and apply anterior nasal pressure.
Evacuation of Blood and Clot
Remove the cotton balls placed for local anesthesia. To evacuate clots, use suction or have patient blow gently. Previously accumulated blood comes out in a gush and then stops. Ongoing bleeding appears as steadily dripping, bright red blood.
Identification of Bleeding Source
Stabilize your hand on the patient’s face, and visualize the septum through the nasal speculum. Examine the Kiesselbach plexus for bleeders. If the offending vessel has stopped bleeding, it will appear as a red dot on the mucosa that may have a small amount of clot on it. If the vessel is still bleeding, active oozing will be visible.
Cauterization of Bleeding Source
A clear view of the bleeding source is mandatory for the use of cauterization methods. Cauterize to cease unilateral septal bleeding only. Bilateral cauterization, whether chemical or electrical, increases the risk of septal perforation.
For chemical cauterization, apply a silver nitrate stick to the red dot or oozing vessel for 5-10 seconds, then roll it over the surrounding area (1 cm) for 5-10 seconds to cauterize feeding vessels. Apply antibiotic ointment over cauterized area. This provides prophylaxis against infection and serves as a topical barrier to prevent desiccation and restart of bleeding.
Electrical cauterization is typically used by an otolaryngologist in the context of endoscopic visualization.
Anterior nasal packing is required when external pressure and cauterization fail to control anterior bleeding, though some clinicians elect to use anterior nasal packing as their first-line approach. The goal is to place an intranasal device that applies constant local pressure to the nasal septum. Traditional gauze packing is sufficient if prefabricated nasal tampons like Rapid Rhino or Merocel are not available (see Equipment).
A prospective study of 42 patients was performed to compare the efficacy and patient tolerance of Merocel and Rapid Rhino nasal tampons. No significant difference in efficacy or patient comfort was revealed between the 2 types of packs. Rapid Rhino produced significantly lower scores for subjective patient discomfort during insertion and removal of pack. 
Packing with commercial products
Anterior packing with prefabricated nasal tampons begins with applying anesthetic to the nasal mucosa with cotton balls or via inhalation. Apply surgical lubricant to the tampon, and gently insert it to the maximum achievable depth. Advance the tampon almost horizontally, along the floor of the nasal cavity.
The Merocel nasal tampon is made of polyvinyl alcohol, which is a compressed foam polymer that is inserted into the nose and expanded by application of water. The nasal tampon swells and fills the nasal cavity and applies pressure over the bleeding point. The Merocel tampon is believed to aggregate clotting factors to reach a critical level, thereby promoting coagulation. The Merocel success rate is 85% (equal to that of traditional ribbon gauze).
The Rapid Rhino anterior balloon tampon is made of carboxymethylcellulose, a hydrocolloid material. It acts as a platelet aggregator and also forms a lubricant upon contact with water. Unlike Merocel, the Rapid Rhino balloon has a cuff that is inflated by air. The hydrocolloid or Gel-Knit reportedly preserves the newly-formed clot during tampon removal.
Packing with gauze
Anterior packing with gauze begins similarly, with the application of anesthetic to the nasal mucosa with cotton balls or via inhalation. Prepare a length of ribbon gauze impregnated with petrolatum jelly. Use bayonet forceps and a nasal speculum to place the gauze in a layered, accordion fashion, packing it from anterior to posterior (see the image below). The gauze should be placed as far posteriorly as is possible.
Failure of anterior nasal packing
If anterior packing failed to stop a confirmed and visualized anterior bleeding source, consider bilateral packing to increase the pressure on the nasal septum. If the anterior bleeding source was unconfirmed and bleeding continues, suspect posterior bleeding.
For a detailed description of posterior nasal packing, see Posterior Epistaxis Nasal Pack.
Topical anesthetics include a 2% (or 4%) solution of lidocaine (see the image below).
Topical nasal vasoconstrictors include the following:
Phenylephrine (Neo-Synephrine Fast-Acting Nasal)
Oxymetazoline (Afrin, Neo-Synephrine 12-hour Maximum Strength Nasal)
Mixture of anesthetics and vasoconstrictors include the following:
Phenylephrine plus lidocaine
Epinephrine (0.25 mL of 1:1000 solution [ie, 0.25 mg]) plus lidocaine (20 mL 2% [ie, 400 mg])
Equipment includes the following:
Procedure lighting (best to use a headlamp)
Commercially produced nasal tampon - Gelfoam (absorbable gelatin), Surgicel (oxidized cellulose), Merocel nasal tampon (see the first and second images below)
Rapid Rhino anterior balloon tampon (see the third image below)
Topical vasoconstrictors and anesthetics
Nasal speculum (see the fourth image below)
Suction apparatus (Frazier suction tip) (see the fifth image below)
Silver nitrate cautery sticks (see the sixth image below)
Epistaxis tray, which at some institutions includes many of the components mentioned above (see the seventh image below)Merocel nasal packing with airway, 8 cm.Smaller Merocel epistaxis pack.Rapid Rhino anterior balloon tampon.Nasal speculum.Frazier suction tip.Silver nitrate sticks.Epistaxis tray.
Place the patient in an upright, not a recumbent, position (see the images below) unless hemodynamic instability prevents this positioning.
All patients treated with nasal packing should receive an antistaphylococcal antibiotic as prophylaxis against sinusitis and staphylococcal toxic shock syndrome. Patients who were cauterized only (and did not receive nasal packing) should gently apply antibiotic ointment to the cauterized area daily for 1 week and use a humidifier while sleeping.
Patients should be given a follow-up appointment for removal of the packing in 48 hours. Instruct the patient to maintain upright posture for 48 hours (including sleep hours) and to avoid laughter or heavy lifting for 24 hours. The goal is the reduction of intracranial venous blood pressure to minimize the likelihood of rebleeding.
Complications of epistaxis and treatment include the following:
Septal pressure necrosis
Neurogenic syncope during packing
Epiphora (from blockage of the lacrimal duct)
Hypoxia (from impaired nasal air movement)
Staphylococcal toxic shock syndrome
If bleeding cannot be controlled, otolaryngologic consultation is necessary. Advanced hemostatic measures may also be necessary, as follows:
Arterial embolization 
Arterial ligation (internal maxillary, sphenopalatine)
Nasal septal dermoplasty