Unless the nose bleed is very brisk or the patient is unstable from blood loss, start conservatively. Have the patient blow their nose to evacuate any clots, then have them squeeze the anterior flexible portion of the nose for 30 minutes with constant, firm pressure. If the patient truly holds pressure the entire time without peeking, well over half of all nose bleeds resolve even in anticoagulated patients.
In adults, for very slow but persistent nose bleeds that do not respond to nose squeezing, you may try oxymetolazine or phenylephrine sprays for vasoconstriction. If available, 4% cocaine (make sure they do not have heart disease) applied to pledgets will often slow down a brisk nose bleed. These treatments can be tried in mild bleeds or in conjunction with packing with more brisk epistaxis.
One other trick that can be used, particularly in coagulopathic patients that may have a hard time tolerating packing, is Floseal. This “hemostatic matrix” gel can be injected with the supplied Angiocath syringe. After you have evacuated the nose of clots, start from the back of the nasal cavity and slowing inject until you reach the front of the nostril. While expensive, this often works quite well.
There are multiple ways to pack a nose. It is good to experiment with different techniques until you find what you like. Ideally one should aim at matching the severity of the nose bleed with the aggressiveness of the packing. Before discussing different types of packing, here is some general information that should be reviewed.
It is very common in the hospital setting to be called to evaluate a patient who is “bleeding out” only to find that their bleeding has spontaneously stopped. Do not extensively pack a patient who has stopped bleeding; either do nothing or at very most use a simple absorbable material (see below).
While the packing is in:
Make sure all patients that receive packing have prophylactic antibiotics to cover gram + bugs (toxic shock, sinusitis) for as long as the pack is in place. Ensure that any patient who has a non-dissolvable nasal tampon device in place receives BID pack moistening with saline or sterile water. Without doing this, the packing may dry to the mucosa and cause significant nasal mucosal degloving upon removal. For all patients who are packed, or those who recently have had nose bleeds, it is helpful to order bedside or blowby humidified air and to have Vaseline applied to the nares BID.
For a general rule of thumb, in patients who are not anticoagulated the packing can remain in place for 4-5 days. In patients who are anticoagulated or have other risk factors (labile hypertension, HHT etc…) 5-7 is appropriate. Just prior to removing, moisten the pack with a vasoconstrictor to decrease the risk of bleeding. Make sure you have all the equipment to repack the nose in the event that the patient rebleeds. Finally, examine the nasal cavity for causative pathologies including cancer, telangiectatic disease (HHT), JNA etc.
This type of packing generally relies upon procoagulative properties and less on tamponade. Common examples are absorbable gelatin foam (Gelfoam) or oxidized cellulose (Surgicel). These are typically used for less aggressive bleeding. This type of packing may also be particularly helpful when combined with a tamponading pack in an anticoagulated patient. As the name implies, this type of packing does not need to be removed and is generally tolerated much better than tamponading packs.
Non-dissolvable anterior packs:
These packs are generally classified as nasal tampons or Vaseline gauze and rely on local pressure to stop bleeding. Examples of commonly used nasal tampons include merocels and rhinorockets. Always make sure to secure the anchored string or ends of the Vaseline gauze to the cheek or nasal ala so that they can be removed rapidly incase of an emergency.
To insert a nasal tampon, have the patient blow their nose to evacuate clots then apply a decongestant/anesthetic medication to facilitate placement. Slide the pack along the floor of the nasal cavity along the septum. Unless the nose is particularly “shallow”, all of the pack should be in the nose with nothing sticking out. For more severe bleeds in patients with wider nasal passages, side-by-side merocels can be used. Infiltrate the pack with either saline or Afrin.
Vaseline gauze takes longer to insert and requires a more cooperative patient. Some argue that Vaseline gauze is superior to nasal tampon devices but in our experience they are very similar. To place Vaseline gauze packing, make sure that you have adequately anesthetized the patients nose with spray. Start from either top to bottom or bottom to top and layer in an accordion like fashion. It is important to make sure that both ends finish out of the nose and not free in the nasopharynx otherwise it may unravel down the back of the throat. It is best to secure both ends outside the nose.
All posterior packs are non-dissolvable and rely on pressure for hemostasis. There are multiple devices that can be used. Common devices include Foley catheters (10-14 Fr), “double balloon devices”, and tonsil sponge rigs. The double balloon devices are the safest and easiest to place. Make sure to read the instructions for each brand as they vary between companies. It is important to monitor the nasal ala for pressure necrosis as the anterior balloon can cause serious damage if over inflated or left up too long. All patients that require posterior packs must be monitored in the hospital with continuous pulse oximetry. When using rigged devices such as the tonsil sponge and Foley catheter, consider ICU monitoring as aspiration could be lethal. Finally, with all posterior packs, make sure that you always have a way retrieve the device in an emergency.
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