++
Anterior nasal packing is required when local measures fail to control epistaxis. This may be due in part to anterior or structural problems in which the bleeding source cannot be identified. It may also be due to heavy or profuse bleeding. The premise behind placing nasal packing is that it provides mechanical pressure and tamponades the bleeding site.12 Note that this is an uncomfortable procedure; therefore, the previously described steps for applying topical anesthesia should be undertaken.
++
Diffuse bleeding is frequently encountered in patients with coagulopathies and blood dyscrasias. The trauma of inserting the nasal packing (e.g., a tampon or petrolatum gauze) can lead to more serious bleeding. A piece of Gelfoam sponge or oxidized cellulose (e.g., Surgicel) is often effective. These substances, coated with an antibiotic ointment (e.g., Bacitracin), provide adequate pressure and hemostasis without extreme trauma to the nasal mucosa. This packing does not need to be removed and will slowly dissolve with the use of a topical saline spray, which may be started within 24 hours of the packing being placed.
++
The two most commonly used absorbable dressings are Gelfoam and Surgicel. Gelfoam is an absorbable gelatin sponge that is readily available and inexpensive. It forms a scaffold for the formation of a blood clot. Surgicel is composed of oxidized and regenerated cellulose. It promotes coagulation better than Gelfoam. Unfortunately, Surgicel results in delayed healing and its use should be reserved for persistent bleeding or when Gelfoam is not available.
++
Absorbable packs may be used for primary and secondary hemostasis. Apply a piece of Gelfoam or Surgicel directly over the site of discrete bleeding or diffuse oozing. The material may be used for secondary hemostasis and be placed over an area that has clotted and stopped bleeding. This can serve as a “Band-Aid” to help prevent the clot from dislodging prematurely and the bleeding to restart. It can be placed over areas that have been chemically or electrically cauterized. An absorbable pack can be placed prior to packing the nasal cavity with a sponge/tampon or gauze. The absorbable pack will prevent the clot from becoming dislodged when the sponge/tampon or gauze is removed.
++
Insert the nasal speculum and identify the scabbed or bleeding site. Apply a piece of Gelfoam or Surgicel over the site. Allow a clot to form onto the absorbable packing. The nasal cavity may then be packed with a sponge/tampon, petrolatum gauze, or a balloon catheter if the Emergency Physician chooses.
++
Two additional absorbable dressings are topical thrombin and collagen. They are expensive, not usually available in the Emergency Department, and should be limited to circumstances where other hemostasis methods have failed. Topical thrombin is made from bovine thrombin. Place a piece of Gelfoam saturated with thrombin over the bleeding site. Thrombin converts fibrinogen to fibrin, bypassing the coagulation cascade, to form a clot. Collagen is available in multiple forms from a variety of sources. It promotes platelet aggregation and forms a scaffold for the formation of a clot. Cover the bleeding site with collagen followed by a piece of Gelfoam.
+++
Chemical Cauterization
++
The location of the bleeding is usually within the anterior nasal cavity, specifically on the anterior nasal septum. Sometimes no active bleeding is found at the time of the evaluation. Suctioning of the nasal cavity will remove clots and may allow the site to bleed and be visualized. A scabbed excoriation or an exposed blood vessel may be found along the nasal septum. Chemically cauterize these areas using silver nitrate applicators.
++
Insert the nasal speculum and identify the scabbed site or the exposed vessel. Apply the silver nitrate under direct vision by rubbing the applicator on the area immediately surrounding the scab or blood vessel. Apply the silver nitrate for 3 to 10 seconds. Do not apply the applicator in any one spot for more than 10 seconds. This may cause mucosal necrosis and damage to the underlying cartilaginous septum. Do not apply the silver nitrate too excessively or in the same spot on both sides of the septum, as this may result in a septal perforation. Apply a topical antibiotic ointment to the area. Consider placing a piece of Gelfoam or Surgicel over the site to help stabilize the clot.
++
A relatively dry field is required to use the silver nitrate applicator. Moderate-to-severe bleeding results in the silver nitrate coagulating the blood. It will not contact the mucosal tissue and bleeding will continue. Attempt to simultaneously suction the blood while using the silver nitrate applicator. Unfortunately, the suction often pulls off the coagulum and the bleeding continues. A final technique is to apply the silver nitrate centripetally around the bleeding site. This will cauterize the feeder vessels and may stop the bleeding. Do not cauterize an area over 0.75 cm in diameter, as this can result in damage to the underlying cartilaginous septum. Pack the nasal cavity with a sponge/tampon, petrolatum gauze, or a balloon catheter if these techniques fail.
+++
Electrical Cauterization
++
Electrocautery can effectively control bleeding if the site is iden-tified. This technique is reserved for the experienced Otolaryngologist. It can cause significant damage to the mucosa and cartilage in inexperienced hands. The technique of electrocautery is not discussed for these reasons.
++
The traditional technique of anterior nasal packing consists of using 0.5 inch wide petrolatum impregnated gauze ribbon (Figure 172-3). This technique is extremely effective but not often used as it is cumbersome, time-consuming, and simpler methods exist (e.g., silver nitrate cautery, sponges/tampons, and balloon catheters).
++
++
Insert the nasal speculum. Grasp one end of the petrolatum gauze with a bayonet forceps. Insert the petrolatum gauze into the nasal cavity and along the nasal floor (Figure 172-3A). Tightly pack the nasal cavity in a layered fashion from bottom to top, extending as far back as possible toward the choanal arch (Figure 172-3B). Be careful to avoid injuring the mucosa overlying the septum and the turbinates. Cut the petrolatum gauze so that it protrudes approximately 2 cm from the nostril. Tape this loose end to the patient's cheek so that it does not accidentally pull the packing out. The packing is later removed by gently pulling on this free end of gauze ribbon protruding from the nostril.
++
The pressure of one-sided anterior nasal packing can bow the septum contralaterally, allowing the packing to “loosen” and the bleeding to restart. Consider packing the contralateral anterior nasal cavity to maintain the septum in the midline and exert pressure on the bleeding site.
+++
Expandable Nasal Sponges/Tampons
++
One of the easiest, quickest, and most effective techniques to control anterior epistaxis is to insert an expandable sponge or tampon (e.g., Merocel packing). These packs are particularly useful when the bleeding is diffuse, a specific site cannot be clearly identified, or the bleeding is heavy. The packs come in various sizes (4.5, 6, 8, and 10 cm), shapes, and styles (Figure 172-4). Initially quite rigid, they soften and expand with the absorption of saline or surrounding blood. A 4.5 or 6 cm sponge is generally adequate for anterior epistaxis.
++
++
Prepare the sponge/tampon. Cut the string from the sponge/tampon as it is not necessary to remove the packing. The sponge/tampon is barely visible when properly inserted. The string hanging from the nostril is irritating to the patient and not cosmetically appealing. Lightly coat two-thirds of the sponge/tampon with a non-water-soluble lubricant (e.g., Vaseline) or antibiotic ointment (e.g., Neosporin). This will prevent premature expansion of the tampon from a water-soluble lubricant or antibiotic ointment, nasal secretions, or blood.
++
Insert and open the nasal speculum within the affected nasal cavity. Grasp the unlubricated end of the sponge/tampon with a bayonet forceps or the dominant thumb and index finger. Insert and advance the sponge/tampon just lateral to the nasal septum, in a vertical position, with the length of the pack directed along the floor of the nose (Figure 172-5A). Advance the sponge/tampon until it is completely within the nasal cavity. The sponge/tampon will expand from the blood and secretions within the nasal cavity (Figure 172-5B). Slowly drip 1 to 3 mL of tap water or saline onto the unlubricated tip of the sponge/tampon to help it expand more rapidly.
++
++
Inspect the oropharynx for bleeding. Persistent bleeding may be due to the septum bowing contralaterally. Pack the contralateral anterior nasal cavity with a sponge/tampon of equal length and size. Observe the patient for oozing or bleeding anteriorly or posteriorly. Continued bleeding requires removal of the sponge/tampon from the bleeding nasal cavity and insertion of a larger one, two small ones, or Vaseline gauze packing.
++
Keep several helpful hints in mind when using the nasal sponges/tampons. Trim large sponges/tampons to 5 to 6 cm in length. The extra length is not required for anterior epistaxis, is uncomfortable for the patient, and is more difficult to remove. The Rhino Rocket is a sponge/tampon within a plastic syringe-like device. Remove the sponge/tampon from the syringe-like device before inserting it. The device can generate significant force and result in mucosal tears, septal injuries, and turbinate injuries. Insert and advance the sponge/tampon rapidly to prevent premature expansion. There is no advantage to using a non-water-soluble antibiotic ointment versus a lubricant. The antibiotic ointment is more expensive and its antibacterial activity lasts only 2 to 4 hours. Insert two sponges/tampons side by side if the patient has a large nasal cavity.
++
Removal of the sponge/tampon is simple and quick. Apply 1 to 2 mL of tap water, saline, or a vasoconstrictor in a dropwise fashion to the tip of the sponge/tampon in the nostril. This will thoroughly hydrate the packing and ensure that it can be withdrawn atraumatically. Allow 5 to 10 minutes to ensure that the packing is completely hydrated. Grasp the end of the sponge/tampon with a hemostat. Place a kidney basin under the patient's nose. Pull quickly and parallel to the floor of the nasal cavity to remove the packing. Epistaxis after removal is often due to dislodgement of the clot. Use an absorbable pack or silver nitrate to stop the bleeding. Look at the sponge/tampon to identify the blood spot and the location of the bleeding.
+++
Inflatable Nasal Balloon Catheters
++
The development of plastic inflatable balloon catheters has simplified the management of epistaxis. The nasal balloons are easy to use and quick to place. They are available in a variety of sizes and shapes (Figure 172-6). They are available with anterior balloons, posterior balloons, or dual balloons. The anterior balloon fills the nasal cavity and acts as an anterior pack. The posterior balloon occludes the nasopharynx and acts as a posterior pack. The inflatable balloons are more expensive than other methods used to manage epistaxis. The increased cost is offset by decreased Emergency Physician contact time as compared with that required for petrolatum (e.g., Vaseline) gauze packing. The balloons have a maximal inflatable volume that is manufacturer-specific, noted on the packaging, and noted on the balloon's inflation hub.
++
++
Prepare the equipment. Select an anterior balloon catheter. A dual-balloon catheter may be used if an anterior balloon catheter is not available. Inflate the balloon with air to just below its maximum capacity. Observe and palpate the balloon for leaks. It may also be inflated in a cup of water to look for leaks. Completely deflate the balloon. Apply a lubricant over the catheter and balloon.
++
Insert the nasal speculum. Insert the catheter with the distal bevel toward the nasal septum. This prevents the distal end of the catheter from getting caught on the turbinates, damaging the mucosa overlying the turbinates, and causing a second source of epistaxis. Advance the catheter along the floor of the nasal cavity until just the inflation hub is protruding from the nostril (Figure 172-7). Inflate the balloon with air and 10 mL less than the maximum volume of the balloon (Figure 172-7). Do not use saline or water to inflate the balloon. Rupture of the balloon can result in aspiration if it is filled with liquid. Do not inflate the balloon with more than the manufacturer's recommended volume. If the patient complains of pain, the balloon may have been inflated larger than the nasal cavity. Slowly deflate the balloon in 2 mL increments until the pain subsides.
++
++
Observe the patient for continued bleeding. Increase the volume of the balloon to the maximum volume if the patient does not complain of pain. The balloon may cause a bowing of the septum to the contralateral side. If the bleeding continues, pack the contralateral anterior nasal cavity to keep the septum in the midline. Observe the patient for further bleeding from the nostril or into the nasopharynx. Continued bleeding suggests that the source is high in the nasal cavity or posterior. The inflatable balloons do not always fill the upper portion of the nasal cavity. Deflate the balloon, pack the high anterior nasal cavity with petrolatum gauze, and reinflate the balloon. Observe the patient for continued bleeding that would require a posterior pack, as described in the following sections.
++
The Rapid Rhino Nasal Pac (Applied Therapeutics Inc., Tampa, FL) is a form of balloon catheter. The balloon is covered with a hydrocolloid fabric that is self-lubricating, easy to insert, and promotes platelet aggregation. It is available in different lengths to accommodate children, anterior epistaxis, and posterior epistaxis. It is also available in a variety of sizes in both a unilateral balloon design and a bilateral balloon design with a single inflation port. The bilateral model allows for bilateral nasal packing with a single inflation port, maintaining equal pressure on both sides of the nasal septum. Dip the fabric covered balloon in sterile water for approximately 30 seconds to prelubricate it before insertion. Insert the balloon and inflate it as described previously. The advantage to this product is the ease of insertion, minimal bleeding upon removal, and patient comfort.13
+++
ENTaxis Nasal Packing
++
A relatively new anterior nasal packing is the ENTaxis (Figure 172-8). It is a natural polymer derived from seaweed and contains calcium alginate.14 The packing provides hemostasis, has healing properties, and is atraumatically inserted and removed. Hydration with normal saline activates the calcium alginate and makes it pliable. The packing expands 300% and conforms to the anterior nasal cavity. It activates platelet aggregation to provide hemostasis, keeps the nasal mucosa moist, and gels into a smooth surface that allows easy removal.
++
++
Prepare the packing. The ENTaxis is packaged in a plastic tray with a tear-off paper lid. Peel the lid completely off the tray. Fill the tray with normal saline to saturate the packing. Remove the hydrated packing from the tray. Squeeze out the excess saline from the packing.
++
Insert a nasal speculum. Grasp the packing on the end opposite the string with a bayonet forceps. Insert the packing along the floor of the nasal cavity. Continue to insert the packing in an accordion-like fashion until the entire packing is within the nasal cavity. The packing will expand and gel to fill the nasal cavity. Secure the string to the patient's cheek or nose with a piece of tape.
++
Removal of the packing is simple and quick. The packing remains hydrated and in a gelled state while within the nasal cavity. Place a kidney basin under the patient's nose. Untape the string from the patient's face. Grasp the packing with a bayonet forceps. Gently withdraw the packing from the nasal cavity.
++
THROMBIN-JMI Epistaxis Kit (Pfizer Pharmaceuticals, New York, NY) is a topical bovine thrombin approved for the management of epistaxis. It works on sites of minor bleeding and oozing. The thrombin causes fibrinogen in the blood to clot without the requirement of platelet activation. The kit contains one vial of thrombin, one vial of diluent, a needle and syringe, and a nasal delivery device.
++
Open the outer packaging to reveal a sterile inner tray with the kit components. Use the syringe with the needle to draw up the saline diluent. Inject the saline diluent into the THROMBIN-JMI vial. Gently swirl the vial to mix the components and reconstitute the thrombin powder. When completely dissolved, draw the thrombin solution into the syringe. Remove the needle from the syringe and attach the nasal delivery device. Insert the nasal delivery device into the nares. Depress the plunger to spray the thrombin solution onto the nasal mucosa. Remove the device. Allow the solution to form a clot. Apply additional thrombin solution if the bleeding continues. Consider applying a piece of Gelfoam to the newly formed clot to support it.
++
The Floseal Hemostatic Matrix (Baxter Healthcare Corporation, Hayward, CA) is composed of human-derived thrombin and bovine-derived gelatin. It stops bleeding fast and in up to 97% of cases.15 The thrombin–gelatin matrix begins to break down in 3 to 5 days and is gone by 7 days. Floseal does not require platelet activation, allowing it to function in patients taking aspirin and other antiplatelet medications.
++
Floseal is provided in components that must be mixed. The process is more complicated than other thrombin products and can take several minutes. The kit contains all of the required components and supplies. Use the 5 mL syringe and attached needle to draw up the calcium chloride solution. Inject the calcium chloride solution into the lyophilized thrombin vial. Gently swirl the vial to mix the components and reconstitute the thrombin. Draw up the thrombin solution into the syringe. Gently transfer it into the bowl in the kit. Use the empty 5 mL syringe with a female Luer lock to aspirate the thrombin solution from the bowl into the syringe. Connect this syringe to the syringe containing the gelatin matrix granules. Push the plunger to fully transfer the thrombin solution into the gelatin containing syringe. This is considered “one pass.” Transfer the gelatin–thrombin solution back and forth between the syringes for at least 20 passes. Disconnect the syringes. Attach one of the two applicator tips to the syringe containing the gelatin–thrombin solution.
++
Apply a small mound of the Floseal to the bleeding source. The Floseal must remain at the site for 2 minutes. Place a sterile saline-moistened gauze sponge over the Floseal mound to ensure it maintains a seal against the bleeding site. After 2 minutes, remove the gauze and inspect the site. If the gauze adheres to the clot or the Floseal, moisten it with sterile normal saline. If bleeding persists, insert the applicator tip through the Floseal mound and deliver fresh Floseal to the bleeding site. Remove any excess Floseal by gentle irrigation after the bleeding is controlled. Consider applying a piece of Gelfoam to the newly formed clot to support it.
++
WoundSeal for Nosebleeds (Biolife LLC, Sarasota, FL) was previously marketed as NoseBleed QR. It is an over-the-counter product that comes in a variety of applications to control bleeding. It is marketed to control epistaxis and external wounds of all types. It consists of a powder containing a hydrophilic polymer and potassium ferrate. When the powder comes in contact with blood, the polymer absorbs liquid and concentrates the red blood cells and plasma proteins under the powder to form a clot. The potassium ferrate releases iron to bind the blood proteins into a clot.
++
The WoundSeal powder is simple to apply. Open the blister pack. Roll the tip of the applicator stick in the powder to completely coat it. Roll the powder coated applicator onto the nasal mucosa. Remove the applicator stick from the nasal cavity. Pinch the nostrils closed for 30 seconds. Reassess the nasal cavity for continued bleeding and the need for additional applications of the powder. Consider applying a piece of Gelfoam to the newly formed clot to support it.
+++
Ankaferd Blood Stopper
++
Ankaferd Blood Stopper (ABS, Ankaferd Health Products LTD, Istanbul, Turkey) is a medicinal plant extract. It is approved in Turkey for the management of postsurgical dental bleeding and external hemorrhage.16 ABS is not currently available in the United States and most other countries. It induces the rapid formation of a hemostatic protein network to control hemorrhage that is not dependent upon coagulation factors and platelets.16 It has been successfully used to control epistaxis.17 ABS may provide a new method to control epistaxis in the future.