Vascular anatomy of the nasal cavity is provided in Figure
239-1. The blood supply of the nasal cavity is provided by
branches of the internal and external carotid arteries. The ophthalmic
artery, supplied by the internal carotid, courses along with the
optic nerve until it branches into the anterior and posterior ethmoidal
arteries, which exit through foramina along the medial aspect of
the orbit. The anterior ethmoidal artery runs along the roof of
the ethmoid sinus until it traverses the cribriform plate to supply
the anterior nasal septum. The external carotid system supplies
the internal maxillary artery (IMA) and the superior labial artery
(from the facial artery). The superior labial branch of the facial
artery joins the anterior ethmoidal and terminal branch of the sphenopalatine
artery (SPA) to form Kiesselbach plexus on the anterior nasal septum,
which is the source of 90% of nosebleeds and can usually be
visualized with anterior rhinoscopy. The most likely source for
posterior bleeds is the SPA, which is a product of the external
carotid system via a terminal division of the IMA and requires endoscopic
or open surgical techniques to visualize.1,2
Arterial blood supply to the nasal cavity. The most common
site of nasal hemorrhage is at Little area, located on the nasal septum.
The most common origin of posterior epistaxis is from the sphenopalatine
and General Assessment
The causes of epistaxis are numerous. Local causes of bleeding
may include digital trauma, a deviated septum, neoplasia, or chemical
irritants such as inhaled corticosteroids or chronic nasal cannula oxygen use.
Rhinosinusitis may be a contributing factor causing mucosal irritation
and friable vasculature. Systemic factors may include chronic renal
insufficiency, alcoholism, hypertension, vascular malformations
such as hereditary hemorrhagic telangiectasia, or any kind of coagulopathy,
including warfarin administration, von Willebrand disease, or hemophilia.
Malignancy can produce bone marrow suppression either from infiltration
or direct toxicity from chemotherapeutic regimens, leading to thrombocytopenia
and difficult-to-control nosebleeds. Many authors believe that uncontrolled,
severe hypertension in the acute setting prolongs hemorrhage and
makes achieving hemostasis more difficult.1–3
A directed history and physical examination is usually sufficient
to evaluate the source of acute epistaxis. Ask about prior or recurrent
epistaxis, duration and severity of the current episode, and laterality.
Ask specifically about NSAID, warfarin, heparin, or aspirin use.
Alcohol or cocaine abuse, trauma, prior head and neck procedures,
as well as a personal and family history of coagulopathy, should
all be addressed. Chronic unilateral epistaxis with nasal obstruction
may suggest neoplasia and warrant direct visualization with endoscopy.
Initial ED assessment for epistaxis begins with a rapid primary
survey addressing potential airway or hemodynamic compromise. Obtain
IV access in patients with severe bleeding, and request cross-matched
blood if there is hemodynamic instability. Reversal of coagulopathy
with blood products can be considered based on clotting studies
and individual patient context, although it is rarely required.
Laboratory evaluation or other ancillary studies are usually not
required unless the hemorrhage is poorly controlled or the history
and physical examination directs it.
Rapid reduction of blood pressure during an episode of acute
epistaxis is generally not advised. Clinically significant nosebleeds
can be frightening to patients, and fear and anxiety can elevate
blood pressure. Blood pressure should be reassessed after hemorrhage
is controlled. For persistent, uncontrolled epistaxis requiring
packing or surgical intervention, some otolaryngologists may advise
a gentle reduction in blood pressure to reduce hydrostatic pressure
and thereby allow clot formation.4
Differentiating an anterior versus posterior source of bleeding
is important for treatment and disposition. Because nasal endoscopy
is not readily available or regularly performed by emergency physicians,
the distinction between anterior and posterior epistaxis is operational
in the ED. Generally, the diagnosis of posterior hemorrhage is only
made in the ED once measures to control anterior bleeding have failed.
Clinical features suggestive of a posterior source include elderly
patients with either inherited or acquired coagulopathy, a significant
amount of hemorrhage visible in the posterior nasopharynx, hemorrhage
from bilateral nares, or epistaxis uncontrolled with either anterior
rhinoscopy or an anterior pack.5
Make preparations for examination and nasal tamponade. The ED should
have a pre-prepared, readily available epistaxis kit or cart. The
kit should include a nasal speculum, bayonet forceps, headlamp,
suction catheter, cotton pledgets, 0.05% oxymetazoline
and 4% lidocaine solutions, silver nitrate swabs, and some
combination of absorbable and nonabsorbable materials for anterior
and posterior packing.
Assemble a good light source, suction, and a nasal speculum.
Have the patient seated and in the “sniffing” position.
The sniffing position is achieved by having the patient flex and
extend the head while keeping the base of the nose straight ahead.
With the patient in this position, brace the speculum by resting
the index finger on the tip of the nose and insert the speculum
with the handle parallel to the floor. Open the blades in a cephalad-to-caudad
direction to visualize the bleeding site and facilitate the performance
of direct hemostatic techniques.6
First, ask the patient to blow the nose to expel clots. If clots
are present, topical vasoconstrictors may not reach the nasal mucosa.
After the nose is cleared, instill a topical vasoconstrictor such
as oxymetazoline or phenylephrine and have the patient place direct
pressure to the nose. The correct technique for direct pressure
requires the patient to lean forward in the “sniffing” position
with the nares pinched between the thumb and the middle finger for
10 to 15 minutes. Have the patient maintain the full duration of
compression to allow adequate time for a hemostatic plug to form.
These initial measures are often sufficient to achieve hemostasis and
facilitate further examination by anterior rhinoscopy.
If two attempts at direct pressure have failed, chemical cauterization
with silver nitrate is the next appropriate step. Before cautery,
anesthetize the nasal mucosa using three cotton pledgets soaked
in a 1:1 mixture of 0.05% oxymetazoline and 4% lidocaine
solution.1 Do not attempt chemical cautery unless
the bleeding vessel is adequately visualized. Electrical cautery
should be left to the otolaryngologist due to the risk of septal
After visualizing the (anterior) bleeding site, silver nitrate
sticks may be judiciously placed just proximal to the bleeding source
on the anterior nasal septum. Silver nitrate requires a relatively
bloodless field, as the chemical reaction leading to precipitation
of silver metal and tissue coagulation cannot proceed in the setting
of active hemorrhage due to washout of substrate. Once a relatively
bloodless field is achieved, gently and briefly (a few seconds)
apply silver nitrate directly to the bleeding site. Chemical cautery
should never be attempted on both sides of the nasal septum. Subsequent
attempts on the same side of the nasal septum should be separated
by 4 to 6 weeks to avoid perforation.7
Foams and Gels
Several hemostatic agents and packing materials are currently
available if pressure and chemical cautery do not work.
Anterior nasal packing with nonabsorbable material, while still
considered safe, may cause significant patient discomfort, usually
requires systemic antibiotics, and requires subsequent packing removal,
after which rebleeding may occur. Thrombogenic foams and gels are
a good option, and they may be considered before insertion of nasal
tampons after attempts at chemical cautery have failed. Gelfoam® (Pfizer,
Inc., New York, NY) and Surgicel® (Ethicon, Inc., Somerville,
NJ) (oxidized cellulose) are effective hemostatic agents that can
be placed simultaneously on visualized bleeding mucosa, and they
are bioabsorbable, so removal is not needed.8,9 FloSeal® (Baxter,
Deerfield, IL), a hemostatic gelatin matrix that is mixed in a syringe
with thrombin and injected into the nasal cavity, is another good
alternative to nonabsorbable packing materials. Mathiasen et al.
performed a prospective, randomized, controlled trial in 70 consecutive
ED patients comparing FloSeal® with traditional nasal packing
in uncontrolled anterior epistaxis.10 On a 10-point
visual analog scale, the FloSeal® group demonstrated statistically
significant differences regarding patient discomfort (1.4 vs. 8.9)
and overall patient satisfaction (9.1 vs 2.9). Furthermore, the
FloSeal® group required less in-person ear, nose, and throat
(ENT) consultation (8.6% vs. 31%) and fewer rebleeding
rates at 7 days (14% vs. 40%).
Anterior nasal packing can be placed if direct pressure, vasoconstrictors, or
chemical cautery are unsuccessful in controlling epistaxis, and
if thrombotic foams and gels are not available. A variety of nasal
balloons or sponges are available, or an anterior pack created by
layering ribbon gauze in the nasal cavity can be used.
Anterior epistaxis balloons (Rapid Rhino®, ArthroCare
Corp., Austin, TX) are easy to use and more comfortable for the
patient than layered strip gauze or nasal sponges. Anterior epistaxis balloons
are available in different lengths and are coated with cellulose
or other materials that promote platelet aggregation. Soak the balloon
with water, and insert it gently along the floor of the nasal cavity.
Once it is in place, inflate slowly with air until the bleeding
stops. Stop inflation if the patient develops discomfort. Do not
inflate with saline, as if a saline-filled balloon ruptures, aspiration
could result. Read specific insertion instructions for each product
before use. If there is a drawstring at the distal end, tape the
drawstring to the face to secure the balloon in place.
Nasal Tampons or Sponges
Preformed nasal tampons or sponges are made of synthetic material
that expands after hydration (Figure 239-2).
These devices are commercially available in 5- and 10-cm lengths,
for anterior and posterior packing, respectively. One product is
Merocel®, a compressed dehydrated polyvinyl acetate sponge.
Coat the sponge with water-soluble antibiotic ointment, and insert
it gently along the floor of the nasal cavity. If the tampon has
not expanded within 30 seconds of placement, gently irrigate it
(while in place) with 5 mL of normal saline to promote expansion.
An alternative method is to cut the Merocel pack lengthwise in two
equal halves, and coat each half with lubricating ointment. Insert
the two halves parallel to each other and parallel with the nasal
septum, and irrigate each half with about 2 cc of normal saline.
This method may provide better compression of septal bleeding.11 Whichever
method is used, then tape the drawstring to the face (Figure
239-2) to secure the tampon in place and prevent inadvertent
aspiration. Merocel® nasal packs work effectively, but
sometimes cause more pain than balloons with removal.12
The Merocel® nasal sponge in its desiccated
(left) and hydrated (right) forms.
If the preceding devices are unavailable, ribbon gauze packing
can be placed to control epistaxis (Figure 239-3).
The key to placement of an anterior nasal pack that will
control epistaxis adequately and stay in place is to lay the packing into
the nasal cavity in an accordionlike manner, so that part of each layer
of packing lies anteriorly, preventing the gauze from falling posteriorly
into the nasopharynx. A. The first layer of 1/4-in.
petrolatum-impregnated gauze strip is grasped approximately 2 to
3 cm from its end. B. The first layer is then placed
on the floor of the nose through the nasal speculum (not pictured
here). The bayonet forceps and nasal speculum are then withdrawn. C. The
nasal speculum is reintroduced on top of the first layer of packing,
and a second layer is placed in an identical manner. After several
layers have been placed, it is often useful to reintroduce the bayonet
forceps to push the previously placed packing down onto the floor
of the nose, making it tighter and more secure. D. A
complete anterior nasal pack can tamponade a bleeding point anywhere
in the anterior nasal cavities and will stay in place until removed
by the physician or patient.
Failure to control hemorrhage after direct pressure, optimal
use of vasoconstrictors, cautery, and anterior packing suggests
(but is not diagnostic of) posterior bleeding. Bilateral anterior packing
may help augment tamponade of the nasal septum. If that is not successful,
the previously mentioned devices are usually available in longer
lengths to provide posterior packing. If longer posterior-length packs
do not work, ENT consultation and assistance is needed. Posterior packing
is associated with higher complication rates, including pressure necrosis,
infection, hypoxia, and cardiac dysrhythmias, especially in patients
with underlying cardiopulmonary disease, and, thus, posterior packing
is generally applied as a temporizing measure while awaiting ENT
support. A formal nasal block may be required for analgesia, as
posterior packing is often quite uncomfortable for the patient,
but topical anesthesia may be sufficient if applied properly. The
Rapid Rhino® has both an anterior (5.5 cm) and posterior
(7.5 cm) balloon that can be inflated as required to tamponade bleeding,
and a similar result can be achieved with a 12F to 14F Foley catheter
with a 30-cc balloon (Figure 239-4). All
posterior packing should be accompanied by an anterior pack.
Anterior and posterior packing. Overinflation of the posterior
balloon can result in pressure necrosis.
The procedure for a posterior pack using a 12F to 14F Foley catheter
with a 30-cc balloon is as follows6:
1. Place patient in “sniffing position,” and
be prepared to perform adequate anterior rhinoscopy with a nasal
speculum, light source, suction, irrigation, and packing materials.
2. Properly anesthetize the nasal mucosa by placing three cotton
pledgets soaked in a 1:1 mixture of 4% lidocaine solution
and 0.05% oxymetazoline intranasally for 5 minutes.
3. After applying topical anesthetic, additional analgesia may be achieved
by local infiltration of 1% lidocaine with epinephrine
in a tuberculin syringe.
4. After lubrication with an appropriate topical antibiotic, advance
the Foley catheter transnasally until visualized in the posterior
5. Inflate the balloon with 7 cc of saline, and gently retract the
catheter approximately 2 to 3 cm until it is lodged in the posterior
6. Inflate the balloon with an additional 5 to 7 cc of saline to
complete the pack.
7. Secure the pack by taping to the patient’s cheek.
8. Note that the balloon should not be inflated to the maximum 30
cc due to risk of pressure necrosis.
9. When resources are extremely limited, a red rubber catheter with attached
cotton padding inserted in a similar fashion may be equally effective.
In patients requiring posterior packing or in cases of uncontrolled
anterior epistaxis, early ENT consultation is likely to be beneficial,
as there are many options available, including IMA embolization,
open surgical approaches, or endoscopy. The approach depends on
the anatomic source and the comfort of the consultant.13–22
Because of the high complication rates and significant patient
discomfort associated with posterior packing, several newer surgical
techniques have been investigated in the management of posterior
epistaxis. Kumar reviewed a pooled case series of 127 patients who
underwent transnasal endoscopic ligation of the SPA and found that
hemostasis was achieved in 98% of cases.13
If hemorrhage is controlled and hemodynamic stability is ensured
over a period of observation (often 1 hour or more in the ED), patients
with anterior epistaxis can be discharged home. Provide patients
with instructions for simple techniques to control repeat hemorrhage,
and consider prescription of inhaled
vasoconstrictors such as oxymetazoline for rebleeding. Patients
with therapeutic warfarin levels may continue medication. Discontinue
NSAIDs for 3 to 4 days. If anterior packing with either absorbable
or nonabsorbable materials has been placed, prescribe an antibiotic
with staphylococcal coverage such as amoxicillin-clavulanic acid. Give
the first antibiotic dose in the ED if possible. Provide ENT or
ED follow up in 2 to 3 days for removal of nonbiodegradable packing.
If the patient requires posterior packing, admission is strongly
advised while considering alternate strategies to achieve hemostasis
and to monitor for complications.