Pocket Emergency Medicine (Pocket Notebook Series) 3rd Ed.


Definition: Bleeding from the nose. 90% of cases are anterior & involve Kiesselbach’s plexus on the septum. 10% of cases are posterior & arise from a branch of sphenopalatine artery.


• Etiologies include URI (most common), trauma, nose picking, environmental irritants (dry air), intranasal drug use, neoplasm, FB, polyps, anticoagulation/TCP

• RFs: Alcoholism, diabetes, anticoagulation, HTN, hematologic disorder

Physical Findings

• Evaluate w/ nasal speculum after having pt blow nose to express clots


• Can usually identify anterior source on exam; posterior bleeds are heavy, brisk, can cause airway compromise. If still bleeding after anterior packing, consider posterior source.

• Check hematocrit if extensive/prolonged bleeding, INR if on warfarin


• If significantly hypertensive, consider antihypertensive to help w/ hemostasis

• Anterior: Start w/ oxymetazoline (Afrin) 3 sprays & hold pressure for 15 min

• May also insert cotton pledgets soaked in cocaine/lidocaine/epinephrine/phenylephrine

• Once vasoconstricted, try to identify a focal bleeding site, then use silver nitrate cautery in ring around bleeding (will not work on active bleeding; caution on septum)

• If bleeding has stopped, observe for 60 min; if recurs, insert a lubricated nasal tampon

• If nasal tampon is not successful, pack the contralateral side. If still unsuccessful, pack bilaterally w/ ¼-in Vaseline gauze accordion-style.

• Posterior: Bleeding can cause airway compromise & be life threatening

• Commercial double balloon device OR pass Foley catheter through nose into posterior pharynx, fill balloon, hold gentle traction


• Anterior: D/c w/ 48 h f/u, typically w/ prophylactic abx for TSS (unproven) (eg, clindamycin, augmentin, or dicloxacillin)

• Posterior: Admit w/ ENT consult