What is the recommended management for epistaxis (nosebleed) using nasal packing?

Epistaxis Nasal Packing Management

Nasal packing should only be used after firm sustained compression to the lower third of the nose for at least 5 minutes has failed to control bleeding, and you should preferentially use resorbable packing materials for patients on anticoagulation, antiplatelet medications, or with suspected bleeding disorders. 1

Stepwise Approach to Nasal Packing

When to Use Nasal Packing

• Apply nasal packing only when ongoing active bleeding persists despite adequate nasal compression (5+ minutes of firm pressure to the soft lower third of the nose) 1
• Use packing when bleeding precludes identification of the bleeding site despite compression 1
• Before packing, always attempt to identify the bleeding source with anterior rhinoscopy after removing any blood clots 1, 2

Type of Packing Selection

For patients on anticoagulation/antiplatelet medications or with bleeding disorders:

• Use resorbable packing materials exclusively (e.g., Nasopore, Surgicel, Floseal, gelatin sponge, fibrin glue) 1
• This reduces the risk of rebleeding upon removal and improves patient comfort compared to nonresorbable materials 1
• The specific type of resorbable material can be chosen based on local availability and clinician experience 1

For other patients:

• Either resorbable or nonresorbable packing (petroleum jelly gauze, BIPP gauze, PVA tampons like Merocel, Rapid-Rhino balloons) may be used 1, 3
• Resorbable packing is underutilized and should be considered more frequently 1

Packing Duration and Removal

• Nonresorbable packing should remain in place for no longer than 5 days 1
• Resorbable packing does not require removal and dissolves with time and nasal saline spray use 1
• Document a clear plan for removal timing at the time of placement 1

Mandatory Patient Education

You must educate every patient receiving nasal packing about the following: 1

Type and Duration

• Specific type of packing placed (resorbable vs. nonresorbable) 1
• Expected duration and removal plan 1

Expected Symptoms

• Nasal obstruction, decreased smell, facial pressure, headaches, nasal drainage, and eye tearing are normal 1
• These symptoms mimic a cold and result from the packing occupying nasal space 1

Activity Restrictions

• Avoid straining, lifting over 10 pounds, bending over, and exercising 1, 4
• Sleep with head elevated 1, 4
• Do not blow nose while packing is in place 1, 4
• If sneezing, keep mouth open 1, 4

Pain Management

• Use acetaminophen (Tylenol) only—it does not increase bleeding risk 1, 4
• Avoid aspirin and ibuprofen unless specifically instructed otherwise 1, 4

Post-Procedure Care

• Apply nasal saline spray frequently throughout the day to keep packing moist and reduce crusting 1, 4
• Use petroleum jelly or saline gel to the nasal vestibule 1-3 times daily 4
• Consider bedside humidifier 4

Warning Signs Requiring Immediate Medical Attention

• Return of blood from nose or mouth 1, 4
• Fever over 101°F 1, 4
• Increasing pain 1, 4
• Vision changes 1, 4
• Shortness of breath or labored breathing 1, 4
• Loss of color around the skin of the nose 1, 4
• Swelling of the face or diffuse skin rash 1, 4

Potential Complications

Infection Risk

• Packing is a foreign material that can support bacterial growth 1
• Low risk of infection spreading to sinuses or, rarely, systemically (toxic shock syndrome) 1
• Consider prophylactic antibiotics in high-risk cases, though this requires discussion of antibiotic risks (allergic reactions, gastrointestinal problems) 1

Structural Complications

• Septal perforation (hole in the nasal septum) 1
• Scar bands (synechiae) in the nasal cavity 1
• Pressure sores on external skin if packing secured with clips 1
• Mucosal injury and decreased blood flow to nasal tissues 1

Respiratory Complications

• Temporary worsening of obstructive sleep apnea due to nasal obstruction 1
• Airway compromise if posterior packing dislodges 5

Management of Anticoagulated Patients

In the absence of life-threatening bleeding, initiate first-line treatments (compression, packing, cautery) before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications 1, 6

This approach prioritizes hemostasis through local measures while maintaining the patient's therapeutic anticoagulation for their underlying condition (reducing thromboembolic morbidity and mortality) 1, 6

Follow-Up Requirements

• Document outcome of intervention within 30 days for patients treated with nonresorbable packing 1
• Follow-up is encouraged even with resorbable packing to monitor proper mucosal healing 4
• Perform or refer for nasal endoscopy in patients with recurrent bleeding despite prior packing or cautery 1, 6

Common Pitfalls to Avoid

• Insufficient initial compression time: Many clinicians proceed to packing too quickly without adequate trial of 5+ minutes of firm compression 2, 6
• Using nonresorbable packing in anticoagulated patients: This significantly increases rebleeding risk upon removal 1
• Inadequate patient education: Failure to explain warning signs leads to delayed recognition of complications 1
• Leaving nonresorbable packing in too long: Duration beyond 5 days increases complication risk 1
• Insufficient moisturization instructions: Patients underestimate the importance of frequent saline spray, leading to excessive crusting 4

Adjunctive Treatments

Topical Tranexamic Acid

• Topical tranexamic acid is probably more effective than other topical agents (epinephrine, phenylephrine) in stopping bleeding within 10 minutes (70% vs 30% success rate) 7
• Can be used as an adjunct to packing or compression 3, 7
• Promotes hemostasis in 78% of patients versus 35% with oxymetazoline alone 3

When Packing Fails

• Surgical treatment (endoscopic sphenopalatine artery ligation) is more effective than nasal packing for posterior epistaxis (97% vs 62% success rate) 3, 8
• Percutaneous embolization is an alternative with 80% success rate, particularly for high-risk surgical candidates 3, 8