What prescription and after‑care should be provided after nasal packing for epistaxis?

Post-Nasal Packing Management for Epistaxis

After achieving hemostasis with nasal packing, prescribe regular nasal saline spray, apply petroleum jelly to the nasal vestibule 2-3 times daily, and educate the patient on warning signs requiring immediate reassessment—while reserving prophylactic antibiotics only for high-risk patients rather than routine use. 1

Immediate Post-Packing Prescriptions

Nasal Moisturization (Essential for All Patients)

• Prescribe nasal saline spray to be used frequently throughout the day to keep the packing moist, reduce crusting, and facilitate dissolution of resorbable materials 1, 2
• Prescribe petroleum jelly or nasal saline gel to apply to the nasal vestibule 2-3 times daily once bleeding has stopped to prevent recurrence 3, 4
• Recommend a bedside humidifier to maintain environmental humidity and prevent mucosal drying 4, 5

Pain Management

• Prescribe acetaminophen (Tylenol) for discomfort, as it does not increase bleeding risk 4
• Explicitly instruct patients to avoid aspirin, ibuprofen, and other NSAIDs unless specifically directed, as these medications increase bleeding risk 4

Antibiotic Prophylaxis Decision Algorithm

High-Risk Patients Who Should Receive Antibiotics

Prescribe anti-staphylococcal antibiotics (cephalexin 500 mg orally twice daily or equivalent) for patients with: 2

• Immunocompromised status (chemotherapy, transplant recipients, HIV/AIDS with low CD4 count)
• Diabetes mellitus
• Chronic obstructive pulmonary disease or congestive heart failure
• Hemodialysis dependence
• Prior MRSA infection (use vancomycin or trimethoprim-sulfamethoxazole instead)
• Prosthetic heart valves or recent cardiac device placement

Standard-Risk Patients (No Routine Antibiotics)

• Do not prescribe prophylactic antibiotics for otherwise healthy patients with nasal packing, as the evidence shows no significant benefit and exposes patients to unnecessary risks including allergic reactions, gastrointestinal problems, and Clostridioides difficile infection 1, 6, 7
• The 2020 American Academy of Otolaryngology-Head and Neck Surgery guideline explicitly states that "several studies suggest that use of systemic antibiotics following nasal packing should not be mandatory" 1
• A 2019 study of 106 emergency department patients found zero documented infections regardless of antibiotic use 6

Duration When Antibiotics Are Prescribed

• Continue antibiotics only while the nasal pack remains in place and discontinue within 24 hours after pack removal 2

Critical Patient Education Requirements

Packing Duration and Removal Plan

• Non-resorbable packing should remain in place for 48-72 hours, with a maximum of 5 days to minimize complications 1, 2
• Resorbable packing does not require removal and will dissolve with regular saline spray use 1, 2
• Schedule a specific follow-up appointment for non-resorbable pack removal—strict adherence prevents complications including infection, septal perforation, and pressure necrosis 1, 2

Warning Signs Requiring Immediate Return

Instruct patients to return immediately or go to the emergency department for: 2, 3

• Active bleeding from nose or mouth despite the packing
• Fever over 101°F (38.3°C)
• Increasing pain or facial swelling
• Vision changes
• Shortness of breath or labored breathing
• Dizziness or signs of significant blood loss

Activity Restrictions

Provide explicit written instructions to: 4

• Avoid nose blowing for at least one week after pack removal
• Avoid strenuous activity, heavy lifting over 10 pounds, and bending over
• Sleep with head slightly elevated
• Sneeze with mouth open to avoid pressure changes in the nasal cavity

Expected Symptoms While Packing Is In Place

Counsel patients that the following symptoms are normal and expected: 1

• Nasal obstruction and decreased ability to smell
• Facial pressure and headaches
• Nasal drainage and tearing from the eyes
• Symptoms similar to a cold
• Temporary worsening of obstructive sleep apnea if pre-existing 2, 4

Common Pitfalls to Avoid

Antibiotic Overuse

• The most common error is prescribing antibiotics to all patients with nasal packing—a 2019 study found 53.7% of emergency physicians prescribed prophylactic antibiotics despite lack of evidence 6
• The available systematic review showed no significant benefit, though individual studies were underpowered to detect rare complications like toxic shock syndrome 1

Inadequate Moisturization Education

• Many patients underestimate the importance of frequent saline spray use, leading to excessive crusting, prolonged congestion, and difficulty with resorbable pack dissolution 4
• Insufficient moisturization increases the risk of mucosal injury and septal perforation 2

Packing Duration Errors

• Never exceed 5 days with non-resorbable packing under any circumstances, as prolonged duration significantly increases risk of infection, mucosal injury, septal perforation, and scar band formation 1, 2
• Evidence demonstrates an 85% control rate with packing durations of only 1-3 days, with no correlation between shorter duration and recurrence 1, 2

Failure to Use Resorbable Packing in Anticoagulated Patients

• For patients on anticoagulants or antiplatelet medications, only resorbable materials (Nasopore, Surgicel, Floseal) should be used to avoid trauma and rebleeding during removal 1, 3
• Non-resorbable packing in anticoagulated patients creates unnecessary risk of traumatic removal and recurrent hemorrhage 2

Special Considerations for Anticoagulated Patients

• Do not discontinue anticoagulation or antiplatelet therapy solely for epistaxis management unless bleeding is life-threatening 3
• Aspirin should be continued in high-risk cardiovascular patients despite epistaxis, as survival benefits outweigh bleeding risks 3
• Restart anticoagulation within 24-48 hours after confirmed hemostasis on an individual basis, balancing thrombosis and bleeding risk 3