›Cautery not possible for posterior source without endoscopic guidance
›ENT consultation required for posterior cautery
›Double-balloon catheter (e.g., Rapid Rhino posterior)
›Preferred device for posterior packing
›Lubricate balloon with sterile water, insert along nasal floor
›Inflate posterior balloon with 7–10 mL of air or saline per manufacturer
›Then inflate anterior balloon to tamponade bleeding
›Foley catheter technique — 10–14 Fr
›Insert to nasopharynx, inflate balloon with 7–15 mL saline
›Pull anteriorly until resistance, secure with umbilical clamp
›Anterior gauze packing or balloon placed simultaneously
›Double-balloon catheters control approximately 70% of posterior epistaxis
›High discomfort — analgesic and anxiolytic support required
›Posterior packing complications
›Airway obstruction from pack displacement — admission mandatory
›Hypoxemia from nasopulmonary reflex — supplemental O2 required
›Sinusitis or otitis media — Eustachian tube occlusion
›Prophylactic antibiotics considered but not universally recommended
›Toxic shock syndrome — Staphylococcal exotoxin
›Anti-staphylococcal antibiotics (amoxicillin-clavulanate 875/125 mg PO BID) if packing >24 hours
›Tissue necrosis from pressure — limit packing duration
›Non-absorbable packing removal at 24–72 hours
Surgical and endovascular interventions
›Endoscopic sphenopalatine artery (SPA) ligation
›Increasingly used as second-line therapy — not third-line
›Success rate >90% — preferred over repeated posterior packing
›Performed under general anesthesia by ENT
›Ethmoid artery ligation — for anterior ethmoid artery bleeding
›External approach or endoscopic
›Endovascular embolization
›Alternative to surgical ligation
›Success rate >90%
›Reserved for surgical failures or poor surgical candidates
›Embolization targets
›Sphenopalatine artery — primary target
›Internal maxillary artery — secondary target
›Risks
›Stroke risk from internal carotid system communication
›Skin necrosis from non-target embolization
Anticoagulation management
›Anticoagulant reversal principles
›Initiate local hemostatic measures before considering reversal
›Withhold next anticoagulant or antiplatelet dose during active bleeding
›Reversal only for life-threatening hemorrhage
›In consultation with hematology and/or cardiology
›Warfarin reversal
›4-factor PCC (Kcentra) — preferred for rapid reversal
›INR 2–3.9: 25 units/kg IV (max 2500 units)
›INR 4–6: 35 units/kg IV (max 3500 units)
›INR >6: 50 units/kg IV (max 5000 units)
›Vitamin K 10 mg IV — sustained reversal effect over 12–24 hours
›FFP 10–15 mL/kg — alternative if PCC unavailable
›DOAC reversal
›Idarucizumab (Praxbind) 5 g IV in two 2.5 g doses — dabigatran reversal
›Andexanet alfa — factor Xa inhibitor reversal (apixaban, rivaroxaban)
›4-factor PCC 25–50 units/kg — alternative when specific reversal unavailable
Blood pressure management
›Hypertension treatment
›Treat elevated BP — reduces rebleeding risk
›Hypertension present in 39% of epistaxis presentations
›Target SBP <160 mmHg during active epistaxis management
›IV antihypertensives if severely elevated and unable to take oral medications
›Oral antihypertensives preferred once bleeding controlled
›Amlodipine 5–10 mg PO or labetalol 200 mg PO
Desmopressin and adjuncts
›Desmopressin (DDAVP)
›Useful for platelet dysfunction or uremia-related bleeding
›0.3 mcg/kg IV in 50 mL normal saline over 15–30 minutes
›Intranasal desmopressin 300 mcg — alternative route
›Von Willebrand disease type 1 — first-line adjunct
›May repeat at 12–24 hours — tachyphylaxis with repeated dosing
›Platelet transfusion
›Platelet count <50 x10^9/L with active bleeding
›Target >100 x10^9/L for surgical intervention