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  • • Persistent epistaxis localized anteriorly on the nasal septum that does not respond to digital pressure, topical vasoconstrictive agents, or cautery.

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  • • Headlight.

    • 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.

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  • • Mucosal abrasion.

    • Septal perforation if excessively tight packing or bilateral cauterization.

    • Neurogenic syncope during packing.

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  • • As in any patient who is hemorrhaging, assess airway, breathing, and circulation first.

    • Wear protective eyewear, gown, and gloves; maintain universal precautions.

    • 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.

    • • Juvenile nasopharyngeal angiofibromas are highly vascular tumors arising in the nasopharynx that usually present as recurrent unilateral hemorrhage in pubescent males.

    • Always provide systemic antibiotic coverage against Staphylococcus species.

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  • • 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.

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  • • Have the patient sit upright (unless hypotensive) and tilt head forward to prevent blood from pooling in the posterior pharynx.

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  • • 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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