Managing a nosebleed: pressure, cautery and packing

What it is

Epistaxis is managed in a ladder: first aid, then finding and treating the bleeding point, then packing, then surgery or embolisation. Most bleeds are anterior, from Kiesselbach's plexus on the front of the septum, and stop with simple measures; posterior bleeds, from branches of the sphenopalatine artery, are heavier, harder to see and more common in older people on anticoagulants. First aid can be done by anyone; cautery and packing by a trained doctor in the emergency room or clinic; ligation and embolisation by ENT and interventional radiology.

Indications and contraindications

• Cautery: a visible anterior bleeding point after the bleeding has slowed with pressure and a topical vasoconstrictor.
• Anterior packing: bleeding continues despite pressure and cautery, or no point is seen.
• Posterior packing or balloon: posterior bleeding or failure of anterior packing; done in hospital.
• Caution: avoid blind packing in suspected skull base fracture; do not biopsy a bleeding nasal mass in an adolescent boy (possible angiofibroma).

How it is done

1. Assess airway, breathing and circulation: pulse, blood pressure and signs of shock come first.
2. First aid: patient sitting, leaning forward, firm continuous pressure on the soft nose for 10–15 minutes; blood is spat out, not swallowed.
3. The clots are cleared (blowing the nose or suction) and a topical vasoconstrictor with local anaesthetic is applied.
4. Anterior rhinoscopy with a headlight and speculum looks for the bleeding point on the septum.
5. A visible point is cauterised, on one side only; an antiseptic cream may be prescribed afterwards.
6. If bleeding continues, an anterior pack (nasal tampon or absorbable material) is placed by a trained doctor.
7. Persistent or posterior bleeding: posterior balloon or pack, admission, and ENT for endoscopic artery ligation or embolisation.

Complications

• Septal perforation after cautery of both sides or repeated cautery.
• Sinusitis, pressure necrosis of the nose and, rarely, toxic shock syndrome with packs.
• Posterior packs: discomfort, hypoxia and a vagal reaction; patients are monitored in hospital.
• Aspiration of blood and hypovolaemia in heavy bleeding.

Next step / Initial management

• Most minor anterior bleeds need no tests; check a full blood count, blood group and coagulation (INR if on warfarin) in heavy, recurrent or anticoagulated bleeding.
• Review anticoagulants and antiplatelets with the prescriber; do not stop them routinely after a controlled bleed. Topical tranexamic acid is an option in some protocols.
• Refer to ENT the same day (urgent) for posterior bleeding, failed packing, haemodynamic instability or a pack that needs removal and review.
• Refer routinely to ENT for recurrent anterior bleeds; refer urgently a unilateral bleed with nasal blockage (tumour, or angiofibroma in an adolescent boy).

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Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: Epistaxis (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2026).

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