General Medical Officer (GMO) Manual: Clinical Section
Epistaxis
Department of the Navy
Bureau of Medicine and Surgery
Peer Review Status: Internally Peer Reviewed
(1) Introduction
The key to obtaining hemostasis in the bleeding nose is to understand the anatomical etiology of the
bleeding source and to exclude concomitant factors, which would inhibit natural hemostatic capability.
(2) Anatomy
Tributaries of the external carotid system (facial, internal maxillary) supply the anterior nasal cavity
whereas the posterior nasal cavity is supplied by the internal carotid system (ethmoid arteries). The area of
the anterior nasal septum (Kiesselbach's plexus) is where a plexus of anastomotic vessels can be found.
This area is the source for nearly 90 percent of all cases of nasal bleeding. These bleeding episodes are
usually incited by local intranasal factors such as deviated nasal septum with crusting, drying, and
subsequent ulceration. Posterior bleeding is more troublesome, difficult to identify, and more challenging to
control.
(3) History
When confronted with a patient with a bleeding nose, first consider the following possibilities:

Is the bleeding due to trauma?

If so, are there associated craniofacial injuries?

Is the patient stable or does he or she require resuscitation?

Are medications or medical disorders interfering with the patients ability to stop bleeding?
(4) Supplies
Collect and arranging the following items:

light source

head mirror

nasal speculum

bayonet forceps

topical vasoconstrictor such as cocaine HCL 4% or (1:1 mixture of 1% phenylephrine and 4%
lidocaine solution)

suction tip

AgN03 applicators

Vaseline gauze

#14 French, Foley catheter, or EPISTAT balloon.
(5) Evaluation
Use of the head mirror frees up both hands so you can get exposure with the nasal speculum and locate the
source of bleeding. Initially, have the patient blow all of the clotted blood from their nose. This will most
likely aggravate the bleeding so be ready with the suction and nasal speculum. After a first quick look,
place a cotton pledgett soaked with a vasoconstrictor in both sides of the nose and leave for 5-10 minutes.
The second look will usually lead to identification of the bleeding source. If the source is identified,
cauterize by holding a silver nitrate (AgN03) applicator firmly over the bleeding source for 15- 30 seconds.
Repeat 2-3 times as needed. Other techniques of mechanical hemostasis include a through and through
septal stitch, electrocautery, injection with adrenaline containing local anesthetic, or packing.
If all attempts to stop bleeding have failed, pack the nose. Use Vaseline gauze, Nu-Gauze with bacitracin
ointment, rolled telfa, or packing sponge. An alternative is to squeeze a tube of bacitracin into the nasal
cavity and place a drip pad. If bleeding continues despite appropriate anterior nasal packing, then a
posterior nasal bleed may be the source. The easiest posterior pack to place is a lubricated #14 French
Foley catheter into the nasopharynx. Inflate the balloon with 10-15cc of saline and pull forward and secure
at the nostril with an umbilical clamp or hemostat. Take care not to cause pressure necrosis of the
columella.
 For any nasal pack left in place over 24 hours an anti-staphylococcal antibiotic should be used to
prevent staphylococcal overgrowth and possible toxic shock syndrome (although rare). For posterior packs,
sedate and manage your patient under observation. Humidified oxygen and hydration will make the patient
comfortable while the packs are in place. Valium can help reduce anxiety.
 The anterior packs should be left in place for 24-48 hours and the posterior packs longer,
usually 48-72 hours. After pack removal, keep the patient on a local vasoconstrictor (Afrin) for an
additional 72 hours and use saline nasal spray for moisture. Follow-up is important to assure a thorough
exam after resolution of the bleeding. Rule out polyps, tumors, or intranasal deformities and refer to an
otolaryngologist as needed for definitive management.
Reference
(a) Deweese and Saunders, Textbook of Otolaryngology, 1994.
Prepared by LCDR David A. Bianchi, MC, USN, Department of Otolaryngology, National Naval
Medical Center, Bethesda, MD. Reviewed by CAPT David H. Thompson, MC, USN, Department of
Otolaryngology, National Naval Medical Center, Bethesda, MD. (1998).