Nine of ten nosebleeds come from Kiesselbach's plexus on the anterior septum — a spot you can see, reach, compress, and cauterize. The failures come from squeezing the wrong part of the nose, quitting the pressure early, and cauterizing blind.
The tenth bleed is posterior, and it plays by different rules: it drips down the throat, it laughs at anterior packing, and it earns a balloon and an admission.
Headlamp, nasal speculum, Frazier suction, silver nitrate sticks, nasal tampons or packing, topical anesthetic/vasoconstrictor per institutional reference. Gown, gloves, face shield — noses spray.
Upright, chin down, basin under the chin. Leaning back sends blood down the airway and hides the volume from everyone.
Have the patient blow out the clots — a clot-filled nose defeats vasoconstrictors, compression, and inspection alike. Then topical vasoconstrictor/anesthetic and a few minutes of patience.
Soft alae pinched over the septum · 10–15 minutes by the clock · no peeking
After clot evacuation and topical vasoconstrictor, pinch the entire soft part of the nose continuously for 10–15 timed minutes — a clip or two tongue depressors taped together spares everyone's fingers. Most anterior bleeds end here, at step one, when step one is actually performed.
Speculum vertical spread · find the point · silver nitrate around then on it · a few seconds
Open the naris with the speculum spreading vertically, good light, suction ready. A visible bleeding point or fresh clot on the anterior septum gets silver nitrate: touch the mucosa around the site first to cut inflow, then the point itself, briefly. Cautery needs a nearly dry field — if it's still flowing, compress again first.
Nasal tampon or layered ribbon · along the nasal floor · lubricated or hydrated
Persistent bleeding despite compression and cautery gets an anterior pack: a lubricated nasal tampon advanced straight back along the nasal floor (then hydrated to expand), or layered packing. Topical tranexamic acid—soaked packing is a reasonable adjunct in many departments — per your local protocol. Recheck the posterior pharynx after packing: continued flow behind the pack is a posterior bleed declaring itself.
Balloon device · ENT · admission · resuscitate like it's hemorrhage
A posterior source needs a posterior balloon (or a Foley in a pinch, per your department's practice), ENT involvement, and admission with monitoring — posterior devices cause real complications and these patients are usually the anticoagulated elderly. Treat significant blood loss like blood loss.
| Scenario | Call | Notes |
|---|---|---|
| Stopped, no pack | home | Moisturizing care (saline spray, ointment), no nose blowing or picking, return precautions |
| Anterior pack in | home + follow-up | Removal in 24–72 hours; prophylactic antibiotics are institution-dependent — follow local guidance |
| Posterior device | admit | Monitored bed, ENT on board — not a discharge conversation |
| Anticoagulated | think twice | Check the numbers where relevant; reversal is a risk-benefit call made with the indication in view, per protocol |
| Recurrent unilateral | ENT referral | Especially older patients — recurrent one-sided bleeding needs a look for a structural cause |
Correct compression — right spot, full duration, clots out first, vasoconstrictor on board — resolves the large majority of anterior bleeds. Most "failed conservative management" was five distracted minutes on the nasal bridge.
Spread the blades vertically, not side to side against the septum you're trying to examine. It's a small hand habit that turns "can't see anything" into a visible bleeding point.
Fingers on the nasal bones compress nothing vascular. The bleeding is on the anterior septum, under the soft alae — that's where the pressure goes (Fig. 1). Teach the patient too; they'll do it at home.
Tilting back doesn't slow bleeding — it reroutes it down the pharynx where it's swallowed, vomited, or aspirated, and where nobody can estimate the loss. Forward, chin down, basin ready.
The pack goes in, the nose looks dry, and the patient quietly swallows blood for an hour. Look at the posterior pharynx after every intervention — that view is the difference between discharge and disaster.
Dry winter air, nasal steroids, oxygen cannulas, and fingernails cause most recurrences. Saline spray, ointment to the septum, and a humidifier prescription prevent the bounce-back better than a second cautery.
A starting template for the procedure note. Text in brackets [ ] and pick-lists in { } are fields to complete. Save it as a SmartPhrase, then edit every field to match the actual procedure.
PROCEDURE: EPISTAXIS CONTROL
Side: {right : left : bilateral} Source: {anterior : posterior}
Anticoagulation/antiplatelet: {none : ***}
Consent: {verbal} consent obtained. Operator: @ME@
Preparation: clots evacuated, topical
{anesthetic/vasoconstrictor per institutional protocol ***}.
Inspection: {bleeding point visualized on anterior septum :
no anterior source identified}.
Interventions (in order):
- Direct compression x *** minutes: {controlled : continued}
- Silver nitrate cautery, {right : left} septum only:
{hemostasis achieved : continued bleeding}
- Anterior packing: {nasal tampon : ribbon : none}, {right :
left} nare
- {Posterior balloon device placed; ENT consulted : n/a}
Post-procedure: posterior pharynx inspected — {no ongoing
bleeding : ***}. Hemostasis {achieved : ongoing, escalated}.
Complications: {none : ***}
Disposition: {home with nasal care instructions and
precautions : packing removal in 24–72 h arranged :
admitted with ENT}.
Electronically signed: @ME@ @TD@ @NOW@
Sample template only — not a validated institutional SmartPhrase. Verify wording, consent, and attestation requirements against your department's documentation, coding, and compliance policies before clinical use.