Epistaxis — Cautery & Packing

First aid

• Sit the patient forward (not tilted back) to avoid swallowing blood.
• Pinch the soft, cartilaginous lower part of the nose firmly and continuously for 10–20 minutes without releasing to check.
• Apply ice/a cold pack to the neck or forehead — may help by reflex vasoconstriction, though evidence is limited.
• Most simple anterior nosebleeds settle with first aid alone.

Assessment

Preparation

• Have the patient blow clots out of the nose first — clot obscures the bleeding point.
• Apply a topical local anaesthetic/vasoconstrictor spray (e.g. co-phenylcaine) to the nasal mucosa 5–10 minutes before examination — this improves visualisation and reduces discomfort.
• Use a headlight and nasal speculum for a clear view, with suction available.

Silver nitrate cautery

1. Visualise the bleeding point

   Identify the specific vessel or area on the anterior septum after clearing clot and applying topical anaesthetic/vasoconstrictor.

2. Cauterise around, then the point

   Touch the silver nitrate stick to the tissue immediately surrounding the bleeding point first, then to the point itself.

3. Brief application only

   Apply for only a few seconds at a time — a grey-white eschar indicates adequate cauterisation; prolonged or excessive application risks deeper tissue injury.

4. One side of the septum only

   Never cauterise both sides of the septum in the same sitting — bilateral simultaneous cautery significantly increases the risk of septal perforation. If the other side also needs treatment, do so at a later, separate visit.

Anterior packing

• Indicated when a bleeding point cannot be identified/cauterised, or bleeding continues despite cautery.
• Insert a nasal tampon or inflatable pack horizontally along the floor of the nose (not upward toward the roof), lubricated, following the natural anatomical plane.
• Confirm the pack has expanded/is seated correctly and check for ongoing bleeding from the other nostril or posteriorly.
• Admission vs same-day ENT review depends on local pathway, bleeding severity and anticoagulation status.

Posterior bleeding

• Suspect with profuse, bilateral or refractory bleeding — higher risk of airway compromise and haemodynamic instability.
• Manage with a dual-balloon epistaxis catheter or a Foley catheter technique for posterior tamponade, alongside resuscitation.
• Urgent ENT involvement — posterior bleeds usually require admission and specialist management.

Anticoagulated patients

• Check FBC and INR (if on warfarin); consider reversal only per local policy and severity — most minor bleeds in anticoagulated patients are still managed with first aid, cautery and/or packing rather than automatic reversal.
• Topical tranexamic acid was previously used to reduce packing rates, but the large multicentre UK NoPAC trial found topical TXA gave no significant benefit over placebo in reducing the need for anterior packing — note that this trial population was predominantly anticoagulated patients, and it does not support routine topical TXA use.
• Do not routinely stop anticoagulation without discussing with the prescribing team/haematology, particularly for high-thrombotic-risk indications.

Discharge advice & admission

• After cautery, prescribe a topical antiseptic cream (e.g. Naseptin — chlorhexidine/neomycin) four times daily for about 10 days to reduce crusting/recurrence.
• Naseptin contains arachis (peanut) oil — avoid in peanut, soya or neomycin allergy; use mupirocin nasal ointment as the alternative in these patients (reserve mupirocin for this indication to limit resistance).
• Safety-net: return if bleeding recurs significantly, especially within the first 24–48 hours; avoid nose-blowing, heavy lifting and hot drinks for a few days.
• Admission criteria: posterior bleeding, packing in a patient who cannot be safely discharged, ongoing significant bleeding, haemodynamic instability, or significant comorbidity/anticoagulation concerns.

References