Last reviewed: March 2026
Contents
MDM Templates
Anterior Epistaxis — Discharge
Patient presents with epistaxis. Bleeding source appears anterior in origin. No hemodynamic instability and no signs of significant blood loss. No history of coagulopathy or current anticoagulant use.
History and exam lower suspicion for posterior source, coagulopathy, hereditary hemorrhagic telangiectasia, or underlying nasal mass. No facial trauma suggesting fracture.
Plan: Direct pressure with nasal clip applied for 15 minutes with head forward. Bleeding controlled with pressure alone. Topical oxymetazoline applied.
Disposition: Discharge with ENT follow-up if recurrent. Return precautions for recurrent uncontrolled bleeding, hematemesis, lightheadedness, or syncope.
Posterior / Refractory Epistaxis — Admit
Patient presents with epistaxis refractory to direct pressure and anterior packing. Bleeding source is unclear and may be posterior in origin. Blood clots were cleared and anterior packing placed, but bleeding persists or recurs around the packing.
History and exam concerning for posterior source given failure of anterior measures, bilateral bleeding, and/or posterior oropharyngeal blood. I have considered coagulopathy, nasal mass, and vascular malformation as contributing factors.
Plan: Anterior packing with TXA-soaked packing placed. Posterior balloon tamponade placed per procedure note. Labs obtained to assess for anemia and coagulopathy.
ENT consulted regarding the patient’s refractory bleeding, packing status, and disposition.
Disposition: Admit for monitoring and ENT evaluation. Return precautions reviewed with the patient.
Epistaxis on Anticoagulation
Patient presents with epistaxis in the setting of anticoagulation with ***. No hemodynamic instability. Bleeding controlled with direct pressure and anterior packing.
History and exam lower suspicion for posterior source. Given anticoagulant use, I have a lower threshold for concern about recurrence and considered whether reversal is indicated based on bleeding severity and indication for anticoagulation.
Plan: Anterior packing placed. Anticoagulation held per discussion with patient. No reversal indicated given controlled bleeding.
If refractory or hemodynamically significant: Labs obtained including CBC, coagulation studies. Reversal considered based on agent and clinical status.
Disposition: Discharge with ENT follow-up in 24–48 hours. PCP follow-up for anticoagulation management. Return precautions for recurrent bleeding, hematemesis, or lightheadedness.
Procedure Notes
Anterior Nasal Packing
Location: *** nare
Time Out: Correct patient, correct procedure confirmed
Anesthesia: Topical oxymetazoline and lidocaine-soaked cotton pledgets placed for 10 minutes
Approach: Blood clots cleared by having the patient blow into a towel. Nasal cavity inspected with headlamp and nasal speculum
Methods: *** (Rapid Rhino / Merocel / ribbon gauze) inserted along the floor of the nasal cavity until fully seated. Balloon inflated with *** mL saline (if applicable). Packing secured
Complications: None. Patient tolerated procedure well. Bleeding controlled post-packing
Clinical Education
Anterior vs Posterior Bleeding
90% of epistaxis is anterior, arising from Kiesselbach’s plexus on the anterior septum. This is a rich anastomotic network of the anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries. Anterior bleeds are typically unilateral, visible on direct inspection, and respond to direct pressure.[1]
Posterior bleeds originate from branches of the sphenopalatine artery in the posterior nasal cavity. Clues to a posterior source include bilateral bleeding, blood draining into the posterior oropharynx, failure of anterior pressure and packing, and older patients with hypertension or anticoagulation.[1]
Initial Management
Step 1: Clear clots. Have the patient blow their nose into a towel — retained clots prevent vasoconstriction and perpetuate bleeding. Step 2: Apply topical vasoconstrictor (oxymetazoline 0.05% spray or phenylephrine-soaked pledgets). Step 3: Firm pinch across the cartilaginous nose (not the bridge), held continuously for 15 minutes by the clock, with head tilted forward.[2]
If direct pressure fails after 15 minutes, proceed to anterior packing. Options include Rapid Rhino (inflatable balloon), Merocel (expandable sponge), or traditional ribbon gauze with petroleum. Rapid Rhino is preferred for ease of use and patient comfort.[2]
Topical TXA
Topical tranexamic acid (TXA) is an effective adjunct for epistaxis. TXA-soaked cotton pledgets (500 mg in 5 mL saline) applied to the bleeding nare reduce rebleeding rates and time to hemostasis compared to standard packing alone. Multiple RCTs and a 2021 Cochrane review support topical TXA as first-line before or alongside nasal packing.[3]
Practical application: soak a cotton pledget in injectable TXA (100 mg/mL), insert into the bleeding nare, and apply direct pressure. This is particularly useful in patients on anticoagulation or with recurrent anterior bleeds.
Packing Pearls
Rapid Rhino technique: soak the device in sterile water (activates the carboxymethylcellulose coating), insert along the floor of the nasal cavity (not aimed upward), and inflate with the minimum volume needed — typically 5–8 mL. Over-inflation increases pain and mucosal necrosis risk.[2]
Prophylactic antibiotics with packing are not routinely indicated. The concern for toxic shock syndrome with nasal packing is largely historical and based on case reports. Current evidence does not support routine antibiotics for anterior packing left in place <48 hours. Consider coverage only for posterior packing or immunocompromised patients.[4]
Packing removal: anterior packing should be removed or reassessed in 24–48 hours by ENT. Instruct the patient not to remove it themselves.
Anticoagulation Management
Most epistaxis in anticoagulated patients can be controlled with standard measures without reversal. Reversal should be reserved for life-threatening hemorrhage (hemodynamic instability, significant hemoglobin drop, posterior bleed refractory to packing). Hold the anticoagulant and recheck with prescribing physician.[5]
| Agent | Reversal |
| Warfarin | Vitamin K 10 mg IV + 4-factor PCC (KCentra) if life-threatening |
| Apixaban / Rivaroxaban | Andexanet alfa (if available) or 4-factor PCC |
| Dabigatran | Idarucizumab (Praxbind) 5 g IV |
Posterior Epistaxis Pearls
Posterior packing carries significant morbidity. Posterior balloon devices (dual-lumen Rapid Rhino, Foley catheter with 10–15 mL balloon in the nasopharynx) can cause vagal-mediated bradycardia, aspiration, and airway compromise. All patients with posterior packing require continuous monitoring and admission.[1]
Foley catheter technique for posterior packing: insert a 12–14 Fr Foley through the bleeding nare, visualize the tip in the posterior oropharynx, inflate the balloon with 10–15 mL water, then pull anteriorly until seated against the posterior choana. Secure with an umbilical clamp at the nare (pad the alar crease to prevent necrosis). Then place anterior packing around the catheter.
Disposition
Anterior epistaxis controlled with pressure alone: discharge with ENT follow-up PRN. Anterior epistaxis requiring packing: discharge with ENT follow-up in 24–48 hours for pack removal. Posterior packing, hemodynamic instability, or significant bleeding on anticoagulation: admit for monitoring, ENT consult, and possible interventional radiology or operative management.[1]
References
- Tunkel DE et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020;162(1_suppl):S1-S38. PubMed
- Alter H. Approach to the adult with epistaxis. UpToDate. 2024.
- Joseph J et al. Tranexamic acid for patients with nasal haemorrhage (epistaxis). Cochrane Database Syst Rev. 2021;12:CD004328. PubMed
- Biggs TC et al. A systematic review of the role of antibiotics in nasal packing. Rhinology. 2017;55(1):2-7. PubMed
- Christensen NP et al. Epistaxis in anticoagulated patients: current evidence and management. Ear Nose Throat J. 2022;101(9):NP381-NP386. PubMed
tydotphrase.com 