• Nasal speculum.
• Frazier suction, 8F and 10F.
• Bayonet forceps.
• Yankauer suction.
• Tongue retractor/tongue blade.
• Absorbable topical vasoconstrictor (oxymetazoline).
• Expandable cellulose intranasal tampons.
• Antibiotic ointment (eg, bacitracin).
• Layered quarter-inch gauze with petroleum.
• Silver nitrate sticks.
• Hemostatic material.
• Cottonoid pledgets.
• 4% topical lidocaine or tetracaine hydrochloride.
• As in any patient who is hemorrhaging, assess
airway, breathing, and circulation first.
• Wear protective eyewear, gown, and gloves; maintain universal
• Once hemorrhage is controlled, instruct the patient against sneezing
or coughing with his or her mouth closed, bending over, straining,
or nose picking or blowing.
• Do not discharge a patient as soon as the bleeding stops; rather,
observe him or her for at least 30 minutes to ensure that the patient
is stable and the bleeding does not recur.
• Always look in the posterior oropharynx, behind the uvula, to
ensure that blood is not dripping down and being swallowed.
• Do not cauterize both sides of the septum. Loss of the perichondrial
layers on both sides of the septum can result in cartilage necrosis
and septal perforation.
• If a patient has recurrent epistaxis, consider a neoplastic process,
especially if bleeding always occurs on the same side.
• Always provide systemic antibiotic coverage against Staphylococcus species.
• Severe epistaxis may require endotracheal intubation
(for airway obstruction), cardiac monitoring and pulse oximetry,
and vascular access (to administer intravenous crystalloid solution).
• Obtain a history, if possible, about digital nasal trauma, foreign
bodies, hematologic disorders, medications, and nasal fracture.
• Obtain a blood count, clotting screen, and a sample for a cross-match.
• Inform the patient and parents that bleeding will be controlled
in a stepwise fashion.
• If the patient is stable, have patient or assistant maintain firm
digital pressure by pinching the nose closed with a gauze sponge.
• Consider sedation.
• Kiesselbach area (also called Little’s
area) is an area on the anteroinferior septum; it is the most common
site for anterior epistaxis.
• The anterior end of the inferior turbinate is another site where
bleeding can be seen.
• Posterior epistaxis is predominantly from the sphenopalatine
artery and anterior ethmoid artery.
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