Back to Basics: Epistaxis

Back to Basics:  Epistaxis by Jared Klein

Epistaxis is a common ED complaint. There is a wide spectrum of presentation ranging from mild to severe and potentially life threateniing. Read on to learn some of the basics regarding risk factors, types and how to approach!


- 90% anterior on the nasal septum (Kiesselbach’s Plexus), 5-10% posterior

- Risk factors: Inhaled corticosteroids, chronic nasal oxygen use, CKD, alcoholism, HTN, vascular malformations (hereditary hemorrhagic telangiectasia), coagulopathy


- ABCs first!

- Have patient blow nose, then pinch soft part of nose for 15 minutes. Can tape 2 tongue depressors together at the top to make pressure device.

- Mix 4% viscous lidocaine or lidocaine/epinephrine solution with topical alpha-1 agonist such as oxymetazoline. Can soak a cotton ball/gauze and place this in the nostril. Can also consider TXA if no relief after alpha-1 agonist (see prior EMDaily post)

- Examine for bleeding source. Cauterize with silver nitrate just proximal to the source. Be sure not to cauterize on both sides of the septum to avoid risk of perforation. The site must be bloodless for this to work. After, put topical antibiotic ointment over the site.

- If still no resolution, pack with anterior nasal pack. Aim straight back, not up. If using a balloon device (Rapid Rhino), soak the packing in water just prior to inserting. Inflate balloon with air. If using a nasal tampon or sponge (Merocel), insert and then gently irrigate with saline if it has not expanded within 30 seconds of placement.

- If bleeding continued or blood in both nares or posterior pharynx - posterior nasal pack with 2 balloons. Can use a 14-French Foley catheter instead. Always inflate balloons with air, not saline.

- If no relief, consult ENT or IR for possible surgical ligation vs embolization.

Disposition and Plan:

-Once bleeding controlled, observe for 1 hour. If no re-bleeding, can discharge.


-If anterior packing:

-Return in 2 days for packing removal

-Rx amoxicillin 500 mg TID

-If posterior packing:

-Admit for airway monitoring




Tintinalli, Judith, et al. “Nose and Sinuses.” Tintinalli’s Emergency Medicine, 8th ed., McGrath-Hill, 2016, pp 1591 – 1594.

Swadron, S. Mason, J. Herbert, M. (May 2017). EM:RAP – Epistaxis. [Audio Podcast]. Retrieved from HYPERLINK ""