[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical skills](https://durgical.com/en/clinical-skills/) › [Procedures](https://durgical.com/en/clinical-skills/areas/procedures/) › Epistaxis: compression, cautery and nasal packing

# Epistaxis: compression, cautery and nasal packing

- Procedure

A nosebleed is stopped step by step: pressing the soft nose, then sealing the bleeding spot, then filling the nose with a pack if needed.

Updated Nov 13, 2026

## Key points

- About 90% of nosebleeds are anterior, from Kiesselbach's plexus on the anterior septum.
- First aid: sit up, lean forward, spit out blood and pinch the soft part of the nose continuously for 10–15 minutes.
- Cauterise only a visible point, and only one side of the septum at a time, to avoid septal perforation.
- Bleeding from both nostrils or down the throat despite an anterior pack suggests a posterior source: posterior pack, admission and ENT.
- Patients with packs, especially posterior ones, are watched for hypoxia, aspiration of the pack and toxic shock syndrome.

On this page

- The basics Key points
- What it is
- Indications
- Equipment
- Step by step (and why)
- Next step
- Elsewhere in DurgiPedia

- Clinical Complications

- Safety Contraindications and precautions

- Study Test yourself

- Connections Connections

## What it is

Most nosebleeds are anterior and come from Kiesselbach's plexus (Little's area) on the front of the nasal septum, where branches of the internal and external carotid systems meet under thin mucosa. They are common in children and are usually stopped by simple measures. Posterior bleeds arise from branches of the sphenopalatine artery, are more frequent in older people with hypertension, atherosclerosis or anticoagulation, bleed heavily from both nostrils and down the throat, and often need a posterior pack and hospital care. Management follows a ladder. First, assess airway and circulation, sit the patient up leaning forward and compress the soft, cartilaginous part of the nose continuously for 10–15 minutes. Next, clear clots, apply a topical vasoconstrictor with a local anaesthetic and inspect with a headlight and speculum. A visible anterior bleeding point is cauterised chemically with a silver nitrate stick, on one side of the septum at a time. If bleeding continues, an anterior pack (an expanding sponge tampon, an inflatable balloon or ribbon gauze with petroleum jelly) presses on the septum. Bleeding that continues behind an anterior pack suggests a posterior source, treated with a posterior balloon or a urinary catheter balloon in the nasopharynx plus anterior packing, and referral to otolaryngology for endoscopic cautery, arterial ligation or embolisation.

## Indications

- Compression and topical vasoconstrictor: every active nosebleed, as the first step.
- Chemical cautery: a visible anterior bleeding point once bleeding has slowed.
- Anterior packing: anterior bleeding that continues after compression and cautery, or a diffuse anterior ooze.
- Posterior packing: bleeding that persists behind an anterior pack or comes from the back of the nose, as a bridge to definitive treatment.
- Referral for endoscopic cautery, sphenopalatine artery ligation or embolisation: bleeding that persists despite packing or recurs.

## Contraindications and precautions

- Assess airway, breathing and circulation first: heavy bleeding can cause shock and aspiration of blood.
- Suspected skull base fracture after facial trauma: avoid blind packing and posterior balloons; involve a specialist.
- Anticoagulants, antiplatelets, bleeding disorders and hereditary haemorrhagic telangiectasia make bleeding harder to stop and change the approach.
- Never cauterise both sides of the septum at the same visit, and avoid cautery on active brisk bleeding, where it does not work.
- Posterior packs can cause hypoxia and bradycardia: use them with monitoring, and with caution in people with lung or heart disease.

## Equipment

- Gloves, mask, eye protection and apron; a kidney dish and tissues for the patient.
- Headlight, nasal speculum, suction with a fine tip and bayonet forceps.
- Topical vasoconstrictor and topical anaesthetic on cotton pledgets or as a spray.
- Silver nitrate cautery sticks.
- Anterior packs (expanding sponge tampons, inflatable balloons or ribbon gauze with petroleum jelly), posterior or double balloon devices or a urinary catheter, and tape.

## Step by step (and why)

- Assess ABC, check pulse and blood pressure, and sit the patient up leaning forward — this protects the airway and lets blood drain out.
- Pinch the soft part of the nose continuously for 10–15 minutes without checking — direct pressure tamponades the septal vessels.
- Ask about anticoagulants, bleeding disorders and trauma; obtain IV access and bloods if bleeding is heavy — these change the plan.
- Clear clots by blowing or suction and insert pledgets with vasoconstrictor and anaesthetic — this slows bleeding and allows a view.
- Inspect with a headlight and speculum to find the bleeding point — a visible anterior point can be treated without a pack.
- Cauterise a visible point: roll the stick in a ring around it, then on the point, one side only — the ring closes feeding vessels first.
- If bleeding persists, insert a lubricated anterior pack along the floor of the nose, parallel to the palate — the nasal floor runs backward.
- Expand the pack with saline or inflate the balloon slowly; consider packing both sides — the opposite pack gives counter-pressure on the septum.
- If blood still runs down the throat, place a posterior balloon, inflate, pull it forward and add an anterior pack — it seals the choana.
- Tape the strings to the cheek, check the throat and document the time — a loose pack can fall into the airway.

## Complications

- Re-bleeding when the pack is removed or because of an untreated posterior source.
- Pressure necrosis of the alar rim, columella or septum, mostly from tight balloons or strings.
- Sinusitis, otitis media and, rarely, toxic shock syndrome from a retained pack.
- Pack displacement into the pharynx with aspiration or airway obstruction.
- Hypoxia, bradycardia and vagal reactions with posterior packs; septal perforation after bilateral or repeated cautery.

## Next step

- After cautery without packing: advise avoiding nose-blowing, straining, hot drinks and picking for several days, and applying a lubricating ointment.
- Heavy bleeding or anticoagulation: check full blood count, coagulation and group and screen, and review anticoagulants with the prescribing team.
- Anterior pack: arrange removal in 24–72 hours according to local protocol; antibiotic prophylaxis follows local policy.
- Posterior pack or uncontrolled bleeding: admit with monitoring and pulse oximetry and call otolaryngology.
- Recurrent bleeds: look for hypertension, local lesions, hereditary haemorrhagic telangiectasia or a tumour, especially with unilateral obstruction.

## Test yourself

Think of the answer, then tap the question to see it.

## Where do most nosebleeds come from?

From Kiesselbach's plexus (Little's area) on the anterior nasal septum, where branches of the internal and external carotid systems meet.

## How should a patient with an active nosebleed be positioned and how is pressure applied?

Sitting up and leaning forward, spitting out blood, while the soft part of the nose is pinched continuously for 10–15 minutes without releasing to check.

## Why is chemical cautery done on only one side of the septum at a time?

Cauterising both sides of the septum at once can kill the cartilage's blood supply from both sides and cause a septal perforation.

## What suggests a posterior epistaxis?

Heavy bleeding from both nostrils or down the throat that continues despite a well-placed anterior pack, typically in older, hypertensive or anticoagulated patients.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-skills/epistaxis-compression-cautery-and-nasal-packing/)

## Elsewhere in DurgiPedia

- [Approach to nosebleed](https://durgical.com/en/ent/approach-to-nosebleed/)
- [Managing a nosebleed: pressure, cautery and packing](https://durgical.com/en/ent/managing-a-nosebleed-pressure-cautery-and-packing/)
- [Nasal exam: external nose, anterior rhinoscopy and nasal endoscopy](https://durgical.com/en/ent/nasal-exam-external-nose-anterior-rhinoscopy-and-nasal-endoscopy/)
- [Nasal cavity, septum and Kiesselbach's plexus](https://durgical.com/en/ent/nasal-cavity-septum-and-kiesselbach-s-plexus/)

## Connections

## Related 3

- [Coagulation tests: PT/INR, aPTT, fibrinogen and D-dimer](https://durgical.com/en/clinical-skills/coagulation-tests-pt-inr-aptt-fibrinogen-and-d-dimer/)
- [Reading a full blood count](https://durgical.com/en/clinical-skills/reading-a-full-blood-count/)
- [The emergency (ABCDE) station](https://durgical.com/en/clinical-skills/the-emergency-station/)

## Related conditions 8

- [Epistaxis (nosebleed)](https://durgical.com/en/conditions/epistaxis/)
- [Hereditary haemorrhagic telangiectasia (Osler–Weber–Rendu)](https://durgical.com/en/conditions/hereditary-haemorrhagic-telangiectasia/)
- [Arterial hypertension](https://durgical.com/en/conditions/arterial-hypertension/)
- [Nasal fracture and septal haematoma](https://durgical.com/en/conditions/nasal-fracture-and-septal-haematoma/)
- [Sinonasal tumors](https://durgical.com/en/conditions/sinonasal-tumors/)
- [Von Willebrand disease](https://durgical.com/en/conditions/von-willebrand-disease/)
- [Immune thrombocytopenia (ITP)](https://durgical.com/en/conditions/immune-thrombocytopenia/)
- [Toxic shock syndrome](https://durgical.com/en/conditions/toxic-shock-syndrome/)

## In Pharmacology 4

- [Oxymetazoline](https://durgical.com/en/pharmacology/oxymetazoline/)
- [Phenylephrine](https://durgical.com/en/pharmacology/phenylephrine/)
- [Tranexamic acid](https://durgical.com/en/pharmacology/tranexamic-acid/)
- [Lidocaine](https://durgical.com/en/pharmacology/lidocaine/)

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Educational content; it does not replace supervised hands-on training, your institution's protocols or a prescriber's order. A procedure is learnt with a teacher and done only once you are trained to do it.

Sources: [Epistaxis](https://www.ncbi.nlm.nih.gov/books/NBK435997/) (StatPearls (NCBI Bookshelf), 2022); [Anterior Epistaxis Nasal Pack](https://www.ncbi.nlm.nih.gov/books/NBK538304/) (StatPearls (NCBI Bookshelf), 2023); [Posterior Epistaxis Nasal Pack](https://www.ncbi.nlm.nih.gov/books/NBK576436/) (StatPearls (NCBI Bookshelf), 2026).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/clinical-skills/epistaxis-compression-cautery-and-nasal-packing/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-skills/epistaxis-compression-cautery-and-nasal-packing/