What is the proper management of a Foleys (nasal) pack for severe nasal bleeding?

Management of Foley (Nasal) Packing for Severe Epistaxis

For severe nasal bleeding requiring Foley catheter packing, use resorbable materials preferentially in anticoagulated patients, remove nonresorbable packing within 5 days maximum, and provide mandatory patient education about warning signs, post-procedure care, and follow-up plans. 1, 2

Indications for Foley/Balloon Packing

• Apply nasal packing only after firm sustained compression to the lower third of the nose for at least 5 minutes has failed to control bleeding 2, 3
• Use packing when ongoing active bleeding persists and precludes identification of the bleeding site despite adequate compression 1
• Before placing any packing, attempt anterior rhinoscopy after removing blood clots to identify the bleeding source 1

Selection of Packing Type

Use resorbable packing materials exclusively (Nasopore, Surgicel, Floseal, gelatin sponge, fibrin glue) for patients on anticoagulation/antiplatelet medications or with suspected bleeding disorders. 1, 2

• Resorbable packing reduces rebleeding risk upon removal and improves patient comfort compared to nonresorbable materials 1, 2
• For patients without bleeding risk factors, either resorbable or nonresorbable packing (including Foley catheters or balloon devices like Rapid-Rhino) may be used 4

Duration and Removal Protocol

• Nonresorbable packing (including Foley catheters) must remain in place for no longer than 5 days 2
• Prolonged balloon packing beyond this timeframe causes severe local complications including damage to nasal mucosa, septum, and alar skin 5
• Resorbable packing does not require removal and dissolves with nasal saline spray use over time 2
• Rebleeding occurs in approximately 30% of posterior epistaxis cases, with 44% of rebleeding episodes occurring within 24 hours of admission 6
• Pack removal within 48 hours after admission increases rebleeding risk (OR 3.07) 6

Mandatory Patient Education

Every patient receiving nasal packing must be educated about the type of packing placed, expected duration, removal plan (if nonresorbable), and warning signs requiring immediate reassessment. 1, 2

Expected Normal Symptoms

• Nasal obstruction, decreased smell, facial pressure, headaches, nasal drainage, and eye tearing are normal and mimic cold symptoms 2

Activity Restrictions

• Avoid straining, lifting over 10 pounds, bending over, and exercising 2
• Sleep with head elevated 2

Post-Procedure Care

• Apply nasal saline spray frequently throughout the day to keep packing moist and reduce crusting 2
• Use petroleum jelly or saline gel to the nasal vestibule 1-3 times daily 2
• Consider using a bedside humidifier 2

Warning Signs Requiring Immediate Medical Attention

Instruct patients to seek emergency care immediately if they experience: 2

• Return of blood from nose or mouth
• Fever over 101°F
• Increasing pain
• Vision changes
• Shortness of breath or labored breathing

Complications and Prophylaxis

• Packing is foreign material that can support bacterial growth with low risk of sinusitis (21% incidence) or toxic shock syndrome 2, 6
• Consider prophylactic antibiotics in high-risk cases, though this requires discussion of antibiotic risks including allergic reactions and gastrointestinal problems 2
• Severe local complications from prolonged balloon packing include mucosal damage, septal injury, and soft tissue necrosis 5

Management in Anticoagulated Patients

• Initiate first-line treatments (compression, packing, cautery) before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications 1, 2
• Blood transfusions were required in 12.3% of posterior epistaxis cases in one series 6

Follow-Up Requirements

• Document outcome of intervention within 30 days for all patients 1, 2
• Follow up even with resorbable packing to monitor proper mucosal healing 2
• If bleeding recurs despite prior packing or cautery, perform or refer for nasal endoscopy to identify the bleeding site and guide further management 1
• If bleeding persists despite packing, evaluate candidacy for surgical arterial ligation or endovascular embolization 1

Critical Pitfall to Avoid

Early nasendoscopy under general anesthesia should be considered if bleeding cannot be controlled with regular packing, rather than prolonging balloon packing duration beyond 5 days. 5 Surgical intervention was required in approximately 20% of posterior epistaxis cases after initial packing failure 6