The level of evidence supporting management options for epistaxis is poor, consisting mostly of reviews and "how I do it" reports - Jeremy Prager


image by: Ammar Hassan

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ENT Emergencies Pearls, Pitfalls, Tips and Tricks

Step 1: Visualize the bleed

Ensure proper orientation up-down orientation of nasal speculum (see image). If bleeding, ask pt to blow nose gently to clear clots.

Step 2: Anesthetize 

Apply cotton pledget with 1:1 mix of oxymetazoline (Dristan or Afrin) & lidocaine, which may be more effective than cocaine (& less side effects), using bayonet forceps. Leave in place for 5–10 minutes with the nose *firmly* clamped.

Step 3: Cauterize 

Remember eye and face protection, as silver nitrate causes sneezing. Cauterize dry edges of bleeding site (ie around the site, not on it), for 10–15 seconds maximum.…

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 ENT Emergencies Pearls, Pitfalls, Tips and Tricks

There is no evidence that hypertension causes nosebleeds. Usually high BP results from pain or anxiety. Our experts recommend treating these symptoms to manage hypertension in epistaxis patients.

Rapid Rhino

Rapid Rhino consists of an outer layer of carboxycellulose that promotes platelet aggregation, with an inflatable balloon that compresses the nasal cavity upon inflation tamponading the bleeding site. Rapid Rhino have been shown to be as effective as nasal tampons and allow for superior patient comfort on insertion and removal.


Knowledge of the pearls, pitfalls, and troubleshooting tips around managing nosebleeds often can be the difference between a frustrating versus straightforward ED stay for patients.


Patients with facial trauma (even relatively minor nasal trauma or un-displaced nasal fractures) can lacerate the posterior ethmoidal artery. This commonly bleeds a lot, and then stops when the vessel spasms, and then re-bleeds (often through your packing) when the spasm relaxes. This requires operative repair, so refer intermittent heavy bleeders to ENT early.

Life in The Fastlane

Nasal packing can lead to serious infection (Toxic shock syndrome), most of literature and ENT specialist recommend prophylactic antibiotics, until evidence supports or refutes this practise its most probably best practise to follow this and treat with broad spectrum antibiotics.


The level of evidence supporting management options for epistaxis is poor, consisting mostly of reviews and "how I do it" reports. In addition, the majority of literature is written about adult patients, who experience the majority of epsitaxis requiring physician intervention.

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