Management of epistaxis requiring nasal packing in the ED

Minimize examination. Pack with Rapid Rhino using Aerosol Generating Procedure (AGP) precautions. Observe for 1 hour

1. Remove the blue sleeve off the Rapid Rhino pack and soak it in water for 30 sec.
2. Insert the Rapid Rhino pack by sliding it like a nasogastric tube, along the floor of the nose and parallel to the septum (inwards and downward).
3. The pack needs to be inflated with air. Test the pressure on the balloon to ensure adequate inflation and prevent over-inflation.
4. Often after 15 minutes the nose adjusts to the pressure and a few mls extra can be added if needed.

Patients can be considered for discharge home with Rapid Rhino in-situ if they meet all of the following criteria and after discussion with ED Senior Doctor in Ninewells:

• They are not on regular anticoagulant medications
• Observations remain stable and patient is comfortable
• Bleeding stopped
• They live within 30minutes of Ninewells Hospital
• They have access to their own transport
• There is another responsible adult at home

Send home with Tranexamic acid 1g TID unless clear contraindication.

• contraindications to Tranexamic acid: thromboembolic disease, fibrinolytic conditions following DIC, history of convulsions.

Give patient worsening advice and “Going Home with a Nasal Pack” patient information leaflet.

Keep details and PASS ON to ENT registrar who will arrange follow up. If discharged during the Out-of-Hours period, contact the ENT registrar at 7am to pass on patient details.

• Minimize examination.
• Pack with Rapid Rhino.
• Admit through ASRU and discuss with ENT registrar on-call 

• Assess in COVID area of the ED
• Initial management as above but patients packed will need admission
• Discuss case with ENT on-call

If any major concerns then discuss with ENT ST on call. There is no need for prophylactic antibiotics unless pack is to stay in longer than 48hours and this can be addressed by ENT in the morning.

• Assess and manage as per any other major haemorrhage in A+E
• IV access, FBC, U&E, INR if warfarinised, clotting screen if on other anticoagulant, G&S
• Resuscitate as per major haemorrhage protocol if unstable
• Pack nose with Rapid Rhino
• Consider tranexamic acid 1g TDS oral or IV.
• If patient is on Warfarin, please check indication for warfarinisation. If it is out with patient’s therapeutic range and still bleeding heavily discuss with ED Senior Doctor for consideration of FFP transfusion +/- 1-2mg of IV Vitamin K.