Episode 89.0 – Epistaxis

This week we discuss the ED management of anterior and posterior epistaxis.

March 20th, 2017 Download 3 Comments Tags: , , ,

Show Notes

Take Home Points

  1. The first step is managing epistaxis is solid pressure.  This means holding a tight pinch just distal to the nasal bones and hold, without peaking, for at least 5 minutes.  This will stop a good deal of the bleeding.
  2. If you need to do more, start by soaking gauze in either oxymetazoline or epinephrine, mix in some lidocaine to help with anesthesia, pack the nare with that and add on some compression.  Hope fully this stops the bleeding enough that you can see a good bleeder and perform cautery.
  3. Third line of treatment would be to try some soaked gauze, but this time with TXA. Can’t hurt to try!
  4. And then last resort is of course packing. Here make sure the patient is anesthetized with some lidocaine, lubricate the packing well and apply horizonally, no vertically as we are often tempted.

Epistaxis Tray

Show Notes

LITFL: Epistaxis

Core EM: Podcast 18.0 – Influenza Testing and Epistaxis

REBEL EM: Do Patients with Epistaxis Managed by Nasal Packing Require Prophylactic Antibiotics

EM Lyceum: Epistaxis, “Answers”

Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013; 31: 1389-92. PMID: 23911102


  • brendan Carmody says:

    I would have patient blow nose / suction BEFORE followed by vasoconstrictor of choice then apply pressure. Can’t visualize bleeding source if clot is still present and if clot pulled after pressure, then bleeding will re-start making cautery less effective.

  • Roger Helmers, DVM says:

    Loved the podcast (as always) and learned some important points.
    Even for my patients (dogs and cats; I am an emergency veterinarian) this will help with the difficult epistaxis case. Just one comment: The singular for nares is naris, not “nare” as was mentioned in the podcast 🙂

    Keep up the great work!


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