a. Press base of the nose
b. Ice packs
c. Press soft parts of the nose
d. Start tranexemic acid
e. IV fluids
answer: C
Treatment
The aim is to control blood loss and to maintain an open airway:- Ask the person to sit down.
- Advise them to tilt their head forwards to allow the blood to drain from the nostrils.
- Ask the person to breathe through their mouth (this will also have a calming effect) and to pinch the soft part of the nose.
- Reassure and help if necessary.
- Tell the person to keep pinching their nose.
- Advise them not to speak, swallow, cough, spit or sniff because this may disturb blood clots that may have formed in the nose.
- After 10 minutes, tell the person to release the pressure. If the bleeding has not stopped, tell them to reapply the pressure for two further periods of 10 minutes.
- Once the bleeding has stopped and with the person still leaning forwards, clean around their nose with lukewarm water.
- Advise the person to rest quietly for a few hours. Tell them to avoid exertion and, in particular, not to blow their nose, because these actions will disturb any clots.
- clear nose of any clots
- apply topical anesthesia/vasoconstrictors (lidocaine with epinephrine)
- (first line) cautery with silver nitrate can be performed if the site of bleeding is identified (one side of septum only because if both are cauterized this can lead to septal perforation)
- (second line- cautery fails, bleeding site not seen) insert either a traditional Vaseline® gauze pack or a commercial nasal tampon or balloon
- prophylactic anti-staphylococcal antibiotics should be prescribed to prevent sinusitis or toxic shock syndrome
If suspect posterior bleed or anterior packing does not provide hemostasis, consult ENT for posterior packing and further evaluation (bleeding is profuse, from both nostrils, and the bleeding site cannot be identified on speculum examination)
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