Epistaxis Management (Training Physician)

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  • Nose bleeding persists despite direct pressure for 10-20 minutes.
  • Chemical cautery or electrocautery is done if a source is identified.
  • Anterior nasal packing is indicated when no source can be identified or cautery has failed.
  • Posterior nasal packing is indicated when epistaxis cannot be localized anteriorly or controlled with anterior packing.
  • Disrupted anatomy, facial fracture, or nasal hematoma (relative contraindications)
  • Hemodynamic status, airway management, and appropriate resuscitation should be addressed before epistaxis management.
  • ENT chair
  • Headlamp
  • Nasal speculum
  • Bayonet forceps
  • Suction tips, such as Frazier and Yankauer
  • Emesis basin
  • Gown, mask and gloves **UNIVERSAL PRECAUTIONS**
  • Vasoactive topical medication (4% cocaine, 0.25% phenylephrine, epinephrine 1:1000 for topical use, oxymetazoline spray)
  • Silver nitrate sticks or electrocautery (optional)
  • 4 × 4 gauze
  • Antibiotic ointment
  • Nasal tampon or bismuth-iodoform impregnated gauze
  • Foley catheter (16F or 18F with 30-mL balloon) or Brighton balloon (optional)
  • Umbilical clamps
  • The septum is supplied by branches of the internal and external carotid artery.
  • Anterior nosebleeds usually arise from Kiesselbach's plexus (Little's area).
  • Posterior bleeds arise from the sphenopalatine artery at Woodruff's plexus.
  • Crossover between the right and left carotid systems can result in persistent bleeding despite unilateral arterial ligation.
  • The trajectory of the nasal canal is almost perpendicular to the plane of the face.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • Patients with anterior packing should follow-up with an otolaryngologist and begin treatment with penicillin or a first-generation cephalosporin to prevent toxic shock syndrome.
  • All patients with posterior packing should be managed in consultation with otolaryngology and merit admission to the hospital.
  • Instruct the patient to avoid blowing the nose and to refrain from strenuous activity or activities prone to injuring the nose.
  • Continue anticoagulation therapy if INR is in the therapeutic range.
  • Apply antibiotic ointment to the interior nose to reduce recurrence.
  • Failure to control bleeding
  • Toxic shock syndrome
  • Anatomic blockage of the nasal passages
  • Airway obstruction due to dislodged packing
  • Nasovagal reflex
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