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  • Writer's pictureShyam Murali

Epistaxis Brief Review - Michael Plewa, MD

We covered epistaxis in our last flipped classroom session. Here is a quick summary of the management of nose bleeds, courtesy of Dr. Plewa!


  • History: estimated blood loss, history of anticoagulant, thrombocytopenia, anterior or posterior

  • Labs: Consider CBC (platelets), PT, PTT

  • Position patient upright, gown/towel, clamp/squeeze, provide emesis basin/bag, tissues/gauze

  • Don mask/goggles, gown, gloves, headlight

  • Remove clot by gentle nose blow, suction or alligator forceps

  • Visualize anterior plexus for bleeder, gently swab with cotton-tipped applicator to be certain

  • Topical anesthesia, soak pledgets in solution:

Afrin (oxymetazoline) or Neo-synephrine (phenylephrine) with Lidocaine 1-4%
XAP/LET (lidocaine 4%, epinephrine 0.1%, tetracaine 0.4%)

Hemostasis Options

  • Sliver nitrate cautery (few seconds touch, roll, lift), swab with cotton-tipped applicator

  • TXA 500 mg in 5 ml, atomize 1-2.5 ml, or soak pledget/packing

  • Thrombin-JMI (5,000 U powder in 5 ml saline) atomize 1-2.5 ml or soak pledget/packing

  • Insert Merocel sponge (coated with Bacitracin) along floor of nose, then inflate with saline

  • Insert Rapid Rhino (soaked for 30 sec in sterile water), inflate with air 10-20 ml

  • Options: Surgicel or Oxycel (oxidized cellulose), Gelfoam, salt pork, FloSeal (biodegradable, gelatin-thrombin)

  • Persistent anterior: TXA or Thrombin, bilateral or longer packing, trade sponge for Rapid Rhino (more air)

  • Posterior:

7.5/10 cm Rapid Rhino or Merocel (after TXA or Thrombin), contralateral pack or sponge if persistent
Atomize TXA or Thrombin, IV sedation or analgesia:

Disposition Planning

  • Observe for 1 hour, stress-test: ambulate, bend over, move, to observe for re-bleed

  • If posterior pack placed: Admit, supplemental oxygen, monitor, analgesics, antibiotics, ENT consultation

  • If anterior pack placed:

Antibiotics for (Bactrim (MRSA), Keflex, Augmentin) for sinusitis, toxic shock syndrome
Follow-up in 3 days to ENT
  • If no packing:

Avoid picking, blowing; educate regarding 5 min pressure or nose-clamp
Keep moist with saline spray, bacitracin or Vaseline
OTC: NosebleedQR


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