Nose bleeds are a bloody common problem (bad pun intended) – most originating at the front to the nose where there is a cluster of blood vessels – Little’s Area.

In the young the bleeding often starts after trauma (e.g. picking or punching noses). In the elderly however, it is commonly a manifestation of underlying vascular disease.

Step 1: Pressure

The “Hippocratic” method i.e. firmly holding the soft part of the nose with head over a bowl (to collect drips). On average a nose bleed will stop within 7 mins so continuous pressure for 10-15min should stop most. However, it is a long time in practice and your hand aches. so get them to watch the clock.

N.B. We don’t have the plastic nose squeezers in our ED. But you can tap 2 tongue depressors together (pink elastoplast works best)

Step 2 – Reduce bleeding

If Step 1 has not worked then we need to reduce the bleeding (Cautery won’t work if the bleeding isn’t slowed).

1. Analgesia (Xylocaine spray) – because this following can hurt esp. if you get to Steps 3-5
2. Choose an agent – you can use the IV vials in the resuscitation cupboard – we have:
   1. Tranexamic acid – several studies have shown this works well
   2. Adrenaline – one vial of 1:1000 made up to 10ml with saline
   3. Phenylephrine – less likely to cause tachycardia than adrenaline (may be better for the elderly)
3. Soak a cotton ball/gause
4. Insert into nostril
5. Pinch – As above another 10 min

Step 3 – Cautery

For Cautery to work properly the bleeding needs to have slowed. If not you will just have a grey mess.

Kit

• Good light source
• Cautery stick – silver nitrate ( come in black plastic bags)
• Cotton wool stick (in ent box look like a long ear bud)
• Nasal dilator – gently pushing the nose up often works if this is not found
• Suction

Identify the bleeding area place the cautery stick on that spot and just around it. then use the cotton wool stick to press on the cauterised area. This is really important to complete the chemical cautery of the tissues. With out this step cautery may not work properly and some of the silver nitrate my run onto other tissues causing unnecessary damage.

Remember – you shouldn’t cauterise both sides of the septum in one visit as it may cause septal perforation 

Step 4 – Packing

This is often very uncomfortable for patients, but if nothing has worked it may be necessary. we have both foam and balloon tampons in ED.  Which ever you use its important to insert it straight back along the floor of the nasal cavity.

• Foam Tampon – insert dry it will soak up blood and expand institute
• Balloon Tampon – before insertion soak in water to activate gel and inflate when in nose

If packing controls the bleeding then you need to consider whether the patient is safe to discharge and return to ENT clinic in 48 hours or needs admission.

Those who are not safe to discharge:

• Traumatic epistaxis
• Haemodynamic compromise
• Previous nasal packing in last 7 days
• Anticoagulated
• Haemoglobin < 100
• Uncontrolled hypertension
• Significant co-morbidities
• Adverse social circumstances

Step 5 – Posterior/Big bleeds

For some patient the above won’t work and the bleeding is severe. Treat ABC, and think of posterior packing. 

Kit

• Ch 12 catheter
• water 10ml
• Lubrication
• Suction

Remove any anterior pack thats in place. Slide the catheter along the floor of the nasal cavity until it reaches the oropharynx. Once in the oropharynx inflation catheter balloon with 7-8ml water. Then give some traction so the balloon wedges at the back of the nasal cavity. the anterior nose can then be packed as in Step 4

Ensure both ED and ENT seniors are aware of such signifciant bleeds

Patient information leaflet epistaxis