How to manage ongoing epistaxis in a patient with nasal packing in place?

Management of Ongoing Epistaxis Despite Nasal Packing

If bleeding continues despite nasal packing already in place, immediately evaluate for surgical arterial ligation or endovascular embolization rather than replacing or adding more packing. 1, 2

Immediate Assessment and Stabilization

When a patient presents with ongoing bleeding despite nasal packing, first confirm the patient is hemodynamically stable and assess the severity of continued blood loss. 2 Key warning signs requiring urgent intervention include:

• Active bleeding from nose or mouth despite packing 3, 1
• Hemodynamic instability or signs of significant blood loss 2
• Fever over 101°F (suggesting infection/toxic shock syndrome) 3, 1
• Vision changes, shortness of breath, or facial swelling 3, 1

Stepwise Escalation Algorithm

Step 1: Verify Adequate Initial Management

Before escalating, confirm that:

• The packing was placed correctly and covers the bleeding site adequately 1
• Firm sustained compression to the lower third of the nose was applied for at least 5 minutes before packing 1, 4
• A topical vasoconstrictor (oxymetazoline or phenylephrine) was used, which stops 65-75% of cases 2, 5

Step 2: Consider Adjunctive Measures

If packing is in place but bleeding persists:

• Apply additional topical tranexamic acid, which promotes hemostasis in 78% of patients versus 35% with oxymetazoline alone 5
• Ensure the patient is seated with head slightly forward, not tilted back 2
• Verify the patient is avoiding straining, lifting over 10 pounds, bending over, and exercising 3, 1

Step 3: Endoscopic Evaluation

Perform nasal endoscopy to localize the exact bleeding site, which succeeds in 87-93% of cases. 2 This is critical because:

• Posterior epistaxis may originate from the septum or lateral nasal wall, not controlled by anterior packing 2
• Direct visualization allows targeted cauterization of the specific bleeding vessel 2
• Endoscopic cauterization is more effective than arterial ligation alone 5

Step 4: Definitive Surgical Intervention

For persistent or recurrent bleeding not controlled by packing, proceed directly to either endoscopic sphenopalatine artery ligation or endovascular embolization rather than replacing packing. 2, 5 The evidence strongly favors these approaches:

• Endoscopic sphenopalatine artery ligation: 97% success rate versus 62% for conventional packing, with recurrence rates less than 10% versus 50% for packing 2, 5
• Endovascular embolization: 80% success rate with comparable efficacy to surgical methods and recurrence rates less than 10% 2, 5

Critical Management Considerations for Anticoagulated Patients

If the patient is on anticoagulation or antiplatelet medications:

• Do NOT reverse anticoagulation if the patient is hemodynamically stable 2
• Ensure resorbable packing materials (Nasopore, Surgicel, Floseal, gelatin sponge, fibrin glue) were used exclusively, as these reduce rebleeding risk upon removal 1, 4, 5
• Initiate compression, packing, and cautery before considering anticoagulation reversal or withdrawal 1, 4
• Restart anticoagulation within 24-48 hours after confirmed hemostasis, balancing thrombosis versus bleeding risk 2

Common Pitfalls to Avoid

Do not simply replace or add more nasal packing if the first attempt fails. 2 This approach has a 50% recurrence rate and delays definitive treatment. 2

Avoid bilateral simultaneous septal cautery, as this increases the risk of septal perforation. 2

Do not prematurely discontinue antiplatelet medications like aspirin in high-risk cardiovascular patients, as survival benefits outweigh bleeding risks in patients with recent MI or stents. 2

When to Refer to Otolaryngology

Immediate specialist consultation is indicated for:

• Recurrent bleeding despite prior packing or cautery 1, 2
• Suspected posterior epistaxis requiring posterior packing with Foley catheter and tranexamic acid-soaked gauze 2
• Need for endoscopic evaluation or surgical arterial ligation 1, 2
• Recurrent bilateral nosebleeds suggesting hereditary hemorrhagic telangiectasia 2

Post-Intervention Monitoring

If packing remains in place temporarily:

• Apply nasal saline spray frequently throughout the day to keep packing moist 3, 1, 4
• Use petroleum jelly or saline gel to nasal vestibule 1-3 times daily 1, 4
• Remove nonresorbable packing within 5 days maximum 1
• Document outcome within 30 days and schedule follow-up even with resorbable packing to monitor mucosal healing 1, 4, 2