Emergency Department




Who to Admit

  • Packed patients

  • Older, frailer patients who may need help at home or live alone, especially if it is late at night and raised INR.

  • NB Those bleeding torrentially OR for more than 20 minutes despite first aid measures should be directed to A&E and NOT to the ward treatment room

  • Suitable for next emergency clinic: adult patients with small volume, <20-minute bleeds.


Initial Management 

ABCDE approach for all bleeding patients must be employed. Effective initial first aid can prevent many being packed and admitted.


First Aid

For those not in extremis, use gold-standard first aid (also known as Trotter's or Hippocratic method):

  • Sit with head forward over a basin/sink

  • Pinch the fleshy part of the nose (nares) firmly

  • Hold the nose for 20 minutes without peeking

  • Suck on some ice or place ice packs on the forehead or nape of neck

  • Spit out any blood in the mouth: it is emetogenic

  • Keep as calm as possible


Second line measures

If first aid measures are unsuccessful, attempt direct therapy. This includes Silver nitrate cautery or applying a haemostatic matrix like kaltostat.

You should not cauterize large areas or bilaterally simultaneously as this may result in septal perforation and make epistaxis worse.


If you cannot perform direct therapy because of equipment or expertise issues you may have to insert a pack. 

Many units try to avoid packing unless first aid measures have failed. Packing is not a first line treatment for epistaxis. It is generally effective but bear in mind the drawbacks:

  • Mucosal trauma

  • Pain and discomfort for the patient

  • Obstruction of the nasal airway in COPD etc. patients

  • Need for admission/increased length of stay


Nasal Packing

This technique is self-explanatory and technique is only really improved by inserting many packs. The type of pack varies in each trust but the 2 main varieties are:


  • Rapid Rhino – uses air to tamponade the bleeding

  • Merocel – thin sponge nasal tampon that expands with water


Figure 2 – Rapid rhino inflated with 10mls air



Figure 3 – Merocel pack expanded with 10mls water



Additional management 

There is usually no benefit in stopping the warfarin or aspirin of any patients whose bleeding stops with simple measures or an anterior pack. 

If epistaxis is torrential, i.e not responsive to anterior packing, then consider reversing anticoagulation.

Consider treating significant hypertension but beware over-treatment. This involves local policy but often includes Amlodipine and low dose diazepam.



Any bleeding around the pack should prompt early re-assessment. While keeping one eye on your ABCDE approach, you could try: 

  • Ice 

  • Adding air or water if you are using Rapid Rhino 

  • Placing a pack in the contralateral nostril to apply further pressure 

  • Replacing the pack(s)


Be wary of nosebleeds not controlled after two good packs (poorly placed packs with most of the balloon/tampon dangling over the mouth also known as walrus sign).

This does not necessarily mean you should take the patient straight to theatre, but you should be making plans to that effect eg nil by mouth and involve the registrar.


Posterior packing

If the patient is still bleeding despite 2 anterior packs then posterior packing is required. This involves placing 12Ch foley catheter into the oropharynx, inflating the balloon with 8-10mls air and pulling the balloon into the post nasal space.


A rapid rhino pack or BIPP packing should be placed into the nose to tamponade further bleeding. The catheter is clamped in place with an umbilical clamp and jelonet to prevent nasal skin necrosis.


If you are unsure of this technique then call the on call registrar.



Consider urgent surgical arrest of haemorrhage for those:

  • Bleeding despite two or more good nasal packs

  • With torrential bleeding

  • Involve the ENT middle grade/consultant sooner rather than later.



  • NBM

  • Wide bore IV access x2

  • Keep ineffective packs in while waiting to go to theatre and continue first aid measures 

  • Re-send full blood count, clotting and send G&S if not already done

  • Actively replace fluid losses depending on cardiovascular status

  • Reverse clotting abnormalities with Vit K, FFP, platelets etc.

  • Book and discuss with the anaesthetist; consent if you know how



This involves surgical ligation of the sphenopalatine artery endoscopically, open anterior ethmoid artery ligation via modified lynch-howarth incision at the medial aspect of the eye or even ligation of the external carotid.



Before discharge, patients can be advised:

  • Not to blow, pick or otherwise traumatise their nose

  • To avoid piping hot food and drink for a day

  • To avoid strenuous activity or exercise for a day or two 

  • To apply antiseptic cream or soft paraffin to both nostrils twice a day for two weeks, taking care not to push fingers or nozzles right up into the nose

  • About first aid measures in case of a re-bleed

  • To re-attend A&E if they have a nosebleed lasting longer than 15-20 minutes


Author: Andrew Senior

Last Update: 08/11/2015