• Outpatient (usually). Inpatient for severe hemorrhage.
• Elderly patient with posterior bleeds and balloon or packing usually requires admission

• Resuscitation as indicated
• Sedation, analgesic, antihypertensive or anticoagulant reversal as needed
• Patient should be gowned and sitting, if stable. Gown, gloves, and eye protection for examiner.
• Attempt to locate bleeding site using headlamp, suction, nasal speculum and assistant.
  Clear nasal cavity of blood with suction, forceps withdrawal of clot or patient blowing nose.
  If bleeding has stopped, rub suspicious areas with wet cotton tipped applicator to identify site.
  Diffuse ooze or multiple sites suggests systemic cause. In cases of posterior bleed try to identify
  as either roof or low posterior site since each has different arterial supply (will be important if
  arterial ligation is necessary).
• Locating the bleeding site may be difficult if patient presents with bilateral bleed. Usually there
  is only one bleeding site and the blood appears on the other because of:
  • Septal perforation
  • Obstruction of the affected side by pinching or packing
  • Posterior bleed where blood passes behind the nasal septum

  Clues are the side on which bleeding started and a careful examination using suction, headlamp and speculum.

• Anterior bleed:
  • Place pledget soaked in vasoconstrictor and local anesthetic in cavity and pinch nostril
    for several minutes to stop bleeding by direct pressure
  • Remove pledget and visualize vessel. Cauterize with silver nitrate stick directly on vessel
    with firm pressure for 30 seconds.
  • Alternative chemical cautery includes bead of chromic acid or 25% trichloracetic acid.
    Larger vessels respond better to thermal cautery or bipolar electrocautery.
    Avoid indiscriminate cauterization of a large area.
  • If unsuccessful, apply second dose of anesthetic and place anterior pack using
    1/2 x 72 inch ribbon gauze impregnated with petroleum jelly (Vaseline) or nasal tampons.
    Insert in folding layers with bayonet forceps and nasal speculum. Tape 2x2 gauze over nostril
    as drip catch.
• Posterior bleed:
  • Traditional posterior packing is still effective if balloon systems fail to control bleeding.
  • Balloon systems: single large balloon (with or without airway tube) or dual-balloon system
    (10 cc posterior + 30 cc anterior). Insert after local anesthesia, inflate per manufacturer’s
    instructions.
  • Foley catheter method: Use 10–14 Fr Foley placed through nostril to nasopharynx. Inflate balloon
    7–15 cc, pull forward, maintain traction, then insert anterior pack. Secure catheter with cord clamp
    and gauze padding, tape remainder over ear.
• Intractable bleed:
  • Bilateral packing may be required (admission required).
  • Bleeding from roof may be controlled by placing double balloon system with small anterior pack
    above anterior balloon.
  • Intractable bleed will require surgical cauterization or arterial ligation (ideally after visual
    identification of bleeding site). Alternatively, angiographic selective arterial embolization.

• Arterial ligation for intractable bleeding

Bedrest with head at 45 to 90 degrees

No alcohol or hot liquids

Demonstrate proper pinching pressure techniques