Contributor: Meghan Hurley, MD Educational Pearls: 1. Initial Assessment Start with a physical examination: Determine if the bleed is anterior or posterior. Perform a primary survey: assess airway, breathing, and circulation (ABCs). Airway compromise = intubation immediately. If the patient is stable, have them blow out any clots, then re-examine the nares. 2. Topical Medications Anesthetics: provide local anesthesia and pain relief. Lidocaine Tetracaine Vasoconstrictors: reduce bleeding. LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides anesthesia and vasoconstriction. Cocaine pledgets (less common). Tranexamic acid (TXA). Oxymetazoline (Afrin). Cautery (Chemical): If an anterior bleed is visualized, silver nitrate can be applied for cauterization 3. Technique Tips Use a nasal speculum. Spread up and down rather than side to side to avoid injury to the septum. Place LET-soaked gauze in the nares. Apply a nasal clamp for ~15 minutes to compress the vessels. Note that pledgets may cause upper lip numbness 4. Reassessment After 15 minutes, remove materials and inspect for a source of bleeding. If still bleeding and a source is identified, cauterize the site. Observe for 15 minutes to monitor for recurrence of bleeding. 5. Packing If the above measures fail to control bleeding: Anterior packing: Nasal tampon (Merocel) Convenient for outpatient removal. Balloon device Inflate the anterior balloon for compression. Posterior packing: More complex, should consult ENT for additional assistance. 6. Disposition & Follow-Up Although rare, toxic shock syndrome is a possible complication of nasal packing. Antibiotic prophylaxis is controversial, but may be considered in high-risk patients. Outpatient follow-up if stable: Tampon: The patient can remove it at home. Balloon: Return to ED for removal. 7. Risk Factors for Epistaxis & Prevention Deviated septum, dry environments, and anticoagulant use Advise on humidifier use, nasal saline, and medication review to minimize future episodes. References: Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery. 2020;162(1_suppl):S1-S38. doi: 10.1177/0194599819890327 Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/