eMedicine Specialties > Clinical Procedures > Otolaryngologic and Dental Procedures

Nasal Pack, Anterior Epistaxis

Author: Eric Goralnick, MD, Staff Physician, Department of Emergency Medicine, Yale New Haven Hospital
Coauthor(s): Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Contributor Information and Disclosures

Updated: May 17, 2009

Introduction

Epistaxis is a common problem in the emergency department. It is relatively benign in nature but can produce serious, life-threatening situations. Up to 60% of the population is estimated to have had at least one 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.1

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.2 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 diagram below). Anterior epistaxes exhibit unilateral, steady, nonmassive bleeding. Just 10% of epistaxes are posterior, exhibiting massive bleeding that is initially bilateral.


Nasal vascular anatomy.

Nasal vascular anatomy.

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Nasal vascular anatomy.

Nasal vascular 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)?3

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, cautery usually provides definitive treatment. Cautery can be chemical (silver nitrate) or electrical (hotwire or bipolar cautery).4 If cautery 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 mucosal irritation, which decreases bleeding; and 3) clot formation surrounding the foreign body, which enhances pressure.

Indications

  • Overt or suspected epistaxis after attempt at direct pressure, topical agents, or silver nitrate cautery
  • May be indicated in hematemesis or melena (Posterior epistaxis can present as hematemesis or melena.)

Contraindications

  • Patients with respiratory compromise may first require airway control and mechanical ventilation.
  • Patients with hemodynamic compromise may first require volume and blood product resuscitation.

More on Nasal Pack, Anterior Epistaxis

Overview: Nasal Pack, Anterior Epistaxis
Treatment & Medication: Nasal Pack, Anterior Epistaxis
Multimedia: Nasal Pack, Anterior Epistaxis
References
Further Reading
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References

  1. Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg. Mar 2006;64(3):511-8. [Medline].

  2. Marx, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. 2006.

  3. Leong SC, Roe RJ, Karkanevatos A. No frills management of epistaxis. Emerg Med J. Jul 2005;22(7):470-2. [Medline].

  4. Douglas R, Wormald PJ. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg. Jun 2007;15(3):180-3. [Medline].

  5. Moumoulidis I, Draper MR, Patel H, et al. A prospective randomised controlled trial comparing Merocel and Rapid Rhino nasal tampons in the treatment of epistaxis. Eur Arch Otorhinolaryngol. Aug 2006;263(8):719-22. [Medline].

  6. Frazee TA, Hauser MS. Nonsurgical management of epistaxis. J Oral Maxillofac Surg. Apr 2000;58(4):419-24. [Medline].

  7. Saba HI, Morelli GA, Logrono LA. Brief report: treatment of bleeding in hereditary hemorrhagic telangiectasia with aminocaproic acid. N Engl J Med. Jun 23 1994;330(25):1789-90. [Medline].

  8. Schaitkin B, Strauss M, Houck JR. Epistaxis: medical versus surgical therapy: a comparison of efficacy, complications, and economic considerations. Laryngoscope. Dec 1987;97(12):1392-6. [Medline].

  9. Nasal emergencies and sinusitis. In: Tintinalli JE, Ruiz E, Krome RL. Emergency Medicine: A comprehensive study guide. 4th ed. New York: McGraw-Hill, Health Professions Division; 1996:1083-93.

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Further Reading

Columbia University Department of Otolaryngology/Head and Neck Surgery: Treatment for Nosebleeds

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Keywords

epistaxis, anterior epistaxis, posterior epistaxis, nosebleed, nasal pack, nasal fracture, cautery, cauterize, nasal packing, Merocel, Rapid Rhino anterior balloon tampon, nasal tampon, gauze packing, ribbon gauze, Kiesselbach’s plexus, nasal trauma, desiccation, epiphora, hypoxia, unilateral nosebleed, nose bleed

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Contributor Information and Disclosures

Author

Eric Goralnick, MD, Staff Physician, Department of Emergency Medicine, Yale New Haven Hospital
Eric Goralnick, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Medical Editor

Prajoy P Kadkade, MD, Attending Physician and Assistant Professor, Department of Otolaryngology and Communicative Disorders, North Shore University Hospital (NSUH)-Long Island Jewish Hospital System, Albert Einstein College of Medicine; Director of Otolaryngology, North Shore University Hospital (NSUH)
Prajoy P Kadkade, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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