Epistaxis is a common problem in the emergency department (ED). Although it usually is relatively benign, it can 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. 
A patient with epistaxis must be evaluated expediently. [2, 3, 4] All patients with epistaxis require a thorough examination and control of the bleeding. Epistaxis that has resolved still requires management to prevent rebleeding. 
Ten percent of epistaxes are posterior, exhibiting massive bleeding that is initially bilateral. Posterior epistaxis may present in ways that suggest a more inferiorly located site of bleeding from the aerodigestive tract (eg, hemoptysis, melena, anemia, or just nausea). A posterior source of the bleeding must be sought when epistaxis is bilateral, brisk, and not controlled with anterior nasal packing.
Posterior epistaxis is usually treated by an otolaryngologist, but an emergency practitioner may be called upon to treat this condition in a medical environment with few support services.
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 the ABCs (A irway, B reathing, and C irculation). Next, the source of the bleed should be identified by a thorough examination of the nasopharynx.
A posterior pack is placed to occlude the choanal arch and, in conjunction with an anterior nasal pack, provide hemostasis. Posterior packing can be accomplished with gauze, a Foley catheter, a nasal sponge/tampon, or an inflatable nasal balloon catheter. Posterior packing is very uncomfortable and may necessitate procedural sedation. An anterior nasal pack is always required on the side of a posterior pack, and a contralateral nasal pack is strongly encouraged to maintain the septum midline. 
The nose, like the rest of the face, has an abundant blood supply. The arterial supply to the nose may be principally divided into (1) branches from the internal carotid, namely the branches of the anterior and posterior ethmoid arteries from the ophthalmic artery, and (2) branches from the external carotid, namely the sphenopalatine, greater palatine, superior labial, and angular arteries.
The bleeding site of a posterior epistaxis is either posterior to the middle turbinate or at the posterior superior aspect of the nasal cavity. Branches of the sphenopalatine artery supply the blood for such an epistaxis (see the image below). The vast majority of posterior bleeding sites originate from the septum. 
For more information about the relevant anatomy, see Nasal Anatomy.
Indications for posterior nasal packing include the following:
Failure of anterior packing
Reliable or high suspicion of posterior bleeding (patient spitting out blood, older patient with atherosclerosis, no visible anterior bleeding site)
Temporizing measures until more definitive therapies are obtained include endoscopic ligation by an otolaryngologist or endovascular ligation by an interventional radiologist.
Posterior nasal packing should not be performed in the presence of facial trauma that may include nasal bone and cribriform plate fractures. (See Facial Fractures.)
If the patient is in shock, has altered mental status, or is otherwise not protecting the airway, the airway must be controlled before any nasal packing is attempted.
Good lighting is paramount. A head lamp is optimal, but a reasonable alternative is an overhead lamp.
Have the patient blow his or her nose to expel any clot. Perform a thorough anterior nasal examination to rule out an anterior bleeding source. A brisk posterior bleed may have some anterior flow but predominantly manifests with posterior oropharyngeal blood flow.
See Epistaxis for more information.
Topical Anesthesia and Vasoconstriction
Have the patient nasally insufflate a topical vasoconstrictor, such as oxymetazoline or phenylephrine. To provide anesthesia, add 2% lidocaine solution to the vasoconstrictor first, and then have the patient inhale the combination.
Apply mupirocin (Bactroban) nasal ointment 2% to the double-balloon catheter, and advance the device completely into the nostril. Inflate the posterior balloon with up to 7-10 mL of sterile water. Withdraw the catheter until posterior balloon seats. The balloon stops at the posterior nasal cavity. Inflate the anterior balloon with up to 15-30 mL of sterile water.
Apply padding (eg, Xeroform wrap, iodoform strips) to prevent alar necrosis. Leave the balloons in place for 3-5 days, until coagulopathy and hypertension have been controlled.
Foley Catheter Approach
Apply mupirocin nasal ointment 2% to the Foley catheter, and insert the device into the nostril. Visualize the catheter tip in the back of the throat. Inflate the balloon with up to 10 mL of sterile water. (Do not inflate the balloon to its full 30-mL capacity.) Withdraw the balloon gently until it seats posteriorly.
Pack the anterior nasal cavity with a balloon device, nasal tampon (eg, Rhino Rocket), or layered ribbon gauze. Apply a padded umbilical clamp across the catheter to prevent alar necrosis and to keep the balloon from dislodging.
Posterior packing with 10F Foley catheter
Topical anesthetics include lidocaine (2% solution) (see the image below).
For more information, see Topical Anesthesia.
Vasoconstrictors include the following:
Epinephrine (1:1000 or 1:10,000) (see the images below)
Phenylephrine (Neo-Synephrine Fast-Acting Nasal)
Equipment includes the following:
Posterior packing (gauze method) - Silk suture material, 0 gauge; gauze squares, 4 × 4; catheter (Foley or some other type; not to be inflated); hemostats
Commercially produced anterior nasal tampon
Absorbable gelatin (Gelfoam)
Oxidized cellulose (Surgicel)
Place patient in the upright position (see the image below) unless hemodynamic instability prevents this positioning.
Admit all patients with posterior packing to the hospital for observation. Reflex bradydysrhythmia can develop because of stimulation of the deep posterior oropharynx by the packing. Airway compromise may develop. Posterior packing should be removed in 72-96 hours.
Potential complications include the following:
Nasal septal pressure necrosis
Toxic shock syndrome
Persistent bleeding and restart of bleeding, in spite of above interventions