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HCGH Anterior Epistaxis Management Algorithm— • Can also consider Gelfoam/thrombin piece to area
December 2016; Updated December 2018 of bleeding. Again, will need direct pressure (use for-
ceps to hold in place) and very little/no actual bleed-
Nursing Triage
• Assign ESI triage level based on vitals and ABCs. ing to be effective.
• Remember: not all nosebleeds are from benign sources. • The next intervention is Merocel. Lubricate with
• If there are any concerns for airway compromise, Bacitracin, apply parallel to nasal septum with pa-
consider intubation and ENT page STAT. tient leaning forward; it is always better to apply the
• Get list of medications to include any anticoagulants. larger size; we do not have Merocel with strings.
• Place IV line and send CBC, CMP, INR; type and • If Merocel is not working, remove it and use Rapid
screen if level 1 or 2 ESI. Rhino. Presoak for 30 seconds in water, then apply
• Have patient sit, leaning forward, pressing soft part parallel to nasal septum with patient leaning for-
of nose—apply 3×3 taped tongue depressors as a ward. Inflate balloon with 5–7mL via syringe and
clamp. secure strings with soft tape to side of face.
• Once roomed, place on monitor for vitals, have • You can consider taking a small swath of QuikClot
Afrin, emesis basin, large stacks of non-sterile 4×4s, or Combat Gauze dressing and wrapping it around
suction set-up, and ENT/nasal packing tray ready for the presoaked Rapid Rhino.
provider. • Please note, we do NOT have Rhino Rockets; ENT
has considered these inferior. Also, using the correct
terms helps clarify during over-the-phone consults.
Treatment
• Remove tongue depressor clamp. • If Merocel then Rapid Rhino are not working, page
• Have patient blow out all blood clots. ENT for advice and guidance.
• Two sprays of Afrin to each nostril, which may help • In the interim, the tongue depressor clamp can be
slow bleeding or stop it altogether. left in place for hemostasis (either alone or on top of
• Consider lidocaine topical spray if planning on doing Merocel or Rapid Rhino).
packing (extremely likely if pressure and Afrin are • TXA premixed vial (10mL) comes as 100mg/1mL
not working). concentration (do not use IVPB version in our or-
• Consider Zofran 4mg IV×1 as well as IV fluids if der sets—that is for massive hemorrhage/trauma
clinically safe. ONLY). You will need pharmacy to order it and send
• Consider PO or IV 5mg of vitamin K and/or FFP it to you via the tube system (sometimes it is stocked
(takes 1 hour to thaw and release, so plan ahead in the Pyxis).
based on INR and which anticoagulant the patient is • Consider TXA 500mg (5mL) soaked cotton pledgets
taking), if the patient has an elevated INR. (keep in place for 5–10 minutes) versus atomization
• If the bleeding site is visible, can attempt silver nitrate (using 100mg or 1mL at a time until hemostasis).
cautery—don’t apply directly to septum. Will work This may help slow bleeding but will still need fol-
only if very little/no actual bleeding is taking place. low-on packing with Merocel or Rapid Rhino.

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