Exam technique and pledget placement

Contributor: Meghan Hurley, MD

Educational Pearls:

1. Initial Assessment

• Start with a physical examination:

• Determine if the bleed is anterior or posterior.

• Perform a primary survey: assess airway, breathing, and circulation (ABCs).

• Airway compromise = intubation immediately.

• If the patient is stable, have them blow out any clots, then re-examine the nares.

2. Topical Medications

• Anesthetics: provide local anesthesia and pain relief.

• Lidocaine

• Tetracaine

• Vasoconstrictors: reduce bleeding.

• LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides anesthesia and vasoconstriction.

• Cocaine pledgets (less common).

• Tranexamic acid (TXA).

• Oxymetazoline (Afrin).

• Cautery (Chemical): If an anterior bleed is visualized, silver nitrate can be applied for cauterization

3. Technique Tips

• Use a nasal speculum.

• Spread up and down rather than side to side to avoid injury to the septum.

• Place LET-soaked gauze in the nares.

• Apply a nasal clamp for ~15 minutes to compress the vessels.

• Note that pledgets may cause upper lip numbness

4. Reassessment

• After 15 minutes, remove materials and inspect for a source of bleeding.

• If still bleeding and a source is identified, cauterize the site.

• Observe for 15 minutes to monitor for recurrence of bleeding.

5. Packing

• If the above measures fail to control bleeding:

• Anterior packing:

• Nasal tampon (Merocel)

• Convenient for outpatient removal.

• Balloon device

• Inflate the anterior balloon for compression.

• Posterior packing:

• More complex, should consult ENT for additional assistance.

6. Disposition & Follow-Up

• Although rare, toxic shock syndrome is a possible complication of nasal packing.

  • Antibiotic prophylaxis is controversial, but may be considered in high-risk patients.

• Outpatient follow-up if stable:

  • Tampon: The patient can remove it at home.

  • Balloon: Return to ED for removal.

7. Risk Factors for Epistaxis & Prevention

• Deviated septum, dry environments, and anticoagulant use

  • Advise on humidifier use, nasal saline, and medication review to minimize future episodes.

References:

1. Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery. 2020;162(1_suppl):S1-S38. doi:10.1177/0194599819890327

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4

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