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Epistaxis is one of the most common nasal emergencies. Typically, anterior epistaxis is a benign self-limited event or resolves by applying direct pressure. Pediatric and elderly populations are most commonly affected by epistaxis, frequently due to direct trauma from nose picking or foreign body insertion, friable mucosa, or anticoagulant use with or without hypertension. In the young and middle-aged adult population, another common cause of epistaxis is intranasal drug use, be it pharmaceutical, such as intranasal steroids, or recreational, such as cocaine. While conservative exist to control anterior epistaxis, nasal packing is sometimes required. This activity reviews the indications and contraindications of anterior nasal packing, outlines the procedural technique for several commercially available nasal packing modalities, and discusses care in the immediate postprocedural period. The activity also highlights the role of the interprofessional team in the management of patients with refractory epistaxis. Objectives: Use best practices when performing an efficient and effective evaluation of a patient presenting with epistaxis. Implement proper techniques when placing an anterior nasal pack in a patient for whom conservative methods have failed to achieve hemostasis. Identify the most common complications of anterior nasal packing. Coordinate with the interprofessional team to provide effective care and appropriate follow-up of patients with epistaxis treated with nasal packing. Access free multiple choice questions on this topic.

Epistaxis is one of the most common nasal emergencies, with roughly 1.7 emergency department visits per 1000 patients yearly.[1][2] Typically, anterior epistaxis is a benign self-limited event or resolves by applying direct pressure. Pediatric and elderly populations are most commonly affected by epistaxis, frequently due to direct trauma from nose picking or foreign body insertion, friable mucosa, or anticoagulant use with or without hypertension.[1] In the young and middle-aged adult population, another common cause of epistaxis is intranasal drug use, be it pharmaceutical, such as intranasal steroids, or recreational, such as cocaine. Generally, anterior epistaxis is more common in winter in all age groups; air from heating systems dries the nasal mucosa, making it more prone to irritation and bleeding.[1] If the direct application of pressure for 15 to 20 minutes fails to achieve hemostasis, other methods are available to stop the bleeding. Vasoconstrictive agents and silver nitrate cautery may be applied, but nasal packing may be necessary if epistaxis persists despite these interventions.

The most common complications of anterior nasal packing are pain with insertion or removal of the pack, rebleeding with pack removal, and failure to achieve hemostasis. Sanguineous nasolacrimal duct reflux manifested as bloody tears occurs rarely and is not a true complication, albeit one that patients may find distressing. Other complications of anterior nasal packing include but are not limited to excoriation or pressure necrosis of the nasal mucosa, infections such as sinusitis or toxic shock syndrome, migration of the packing, and aspiration.[16][17][18][19][20] Posterior nasal packing increases the risk of airway obstruction and can induce a nasopulmonary reflex manifesting as bradycardia or respiratory depression due to increased nasopharyngeal pressure; patients are often admitted for continuous pulse oximetry. Excessive pressure in the nasopharynx may also result in necrosis of the soft palate, the prevention of which requires frequent examination.[5]

All emergency medicine providers must be proficient in evaluating and treating epistaxis. In addition, a strong working partnership among otolaryngologists and emergency department clinicians is necessary to provide specialty support for refractory cases and appropriate outpatient follow-up.