Emergency Medicine Hub / HEENT & Ophthalmology • 3 min read • 2 sections

Epistaxis Management & Nasal Trauma

Comprehensive emergency evaluation and protocolized management of acute epistaxis and nasal bone fractures: anterior epistaxis (Kiesselbach's plexus/Little's area, digital trauma, dry air, topical vasoconstrictors, silver nitrate cautery, anterior nasal packing) vs. posterior epistaxis (Woodruff's nasopalatine plexus, sphenopalatine artery branches, elderly hypertensive patients, bilateral epistaxis, blood streaming down posterior oropharynx despite anterior packing, balloon tamponade systems); admission and ICU monitoring criteria; toxic shock syndrome antibiotic prophylaxis; and nasal trauma evaluation (pathognomonic Septal Hematoma requiring immediate drainage to prevent saddle-nose deformity).

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

Proper Direct Pressure

Pinch the SOFT CARTILAGINOUS ALA of the nose (not the nasal bones!) firmly and continuously for 15–20 minutes, head tilted forward

Silver Nitrate Rule

Cauterize actively bleeding vessel for 5–10 seconds; NEVER cauterize both sides of the nasal septum simultaneously (causes septal perforation)

Posterior Bleed Signs

Bleeding persists despite adequate anterior pack, blood streaming down posterior oropharynx, or bilateral flow = POSTERIOR EPISTAXIS

Posterior Balloon Tamponade

Insert dual-balloon pack along nasal floor: inflate posterior balloon with 7–10 mL sterile water, seat firmly, then inflate anterior balloon with 15–20 mL

Posterior Pack ICU Admission

Posterior packs trigger nasopulmonary reflexes (hypoventilation, bradycardia, apnea) and risk asphyxiation; MANDATORY TELEMETRY/ICU ADMISSION

Septal Hematoma Drainage

Boggy, purple swelling of nasal septum following trauma: STAT needle aspiration or horizontal scalpel incision + anterior pack to prevent saddle nose

Alveolar Osteitis (Dry Socket)

Severe throbbing jaw pain and fetid odor occurring 3-5 days after tooth extraction due to premature dislodgement of the blood clot; treat with gentle irrigation and packing with dry socket paste (eugenol/clove oil gauze).

Tooth Avulsion & Hanks Solution

Reimplantation within 60 minutes is critical; transport avulsed tooth in Hanks Balanced Salt Solution (HBSS), cold milk, or saliva (NEVER dry gauze or water); do not touch or scrape root.

Temporomandibular Joint (TMJ) Dislocation

Anterior dislocation after yawning or trauma; patient cannot close mouth; reduction via syringe technique (bite down and roll 5 mL syringe between molars) or traditional intraoral downward/backward mandibular traction.

Bottom-Line Clinical Pearl

Epistaxis is divided into Anterior (90%, Kiesselbach's plexus on anterior nasal septum) and Posterior (10%, Woodruff's plexus/sphenopalatine artery). For anterior epistaxis: blow nose to clear clots, spray Oxymetazoline (Afrin) + Lidocaine, and apply firm, continuous direct cartilaginous compression for 15–20 minutes with head tilted forward. If bleeding continues, locate the vessel and apply Silver Nitrate cautery (cauterize ONE side of the septum only to avoid septal perforation). If cautery fails, place an Anterior Nasal Pack (Merocel or Rapid Rhino). Posterior epistaxis presents with massive bleeding, blood trickling down the posterior pharynx despite anterior packing, or bilateral anterior hemorrhage; it mandates Posterior Balloon Tamponade (e.g., dual-balloon 10–14 French Foley or Epistat) and MANDATORY ADMISSION TO TELEMETRY/ICU (posterior packs trigger the nasopulmonary reflex, producing profound bradycardia, hypoventilation, and fatal dysrhythmias). In nasal trauma, ALWAYS inspect the nasal septum: a bilateral boggy purple swelling is a SEPTAL HEMATOMA that must be incised and drained immediately to avoid cartilage necrosis and permanent 'saddle-nose' deformity.

1. Vascular Anatomy: Kiesselbach's vs. Woodruff's Plexus

Vascular Plexus	Anatomical Location & Arterial Contributors	Clinical Frequency & Severity	First-Line Hemostatic Protocol
Kiesselbach's Plexus (Little's Area)	Anterior-inferior nasal septum. Anastomosis of 5 arterial branches: (1) Anterior ethmoidal, (2) Posterior ethmoidal, (3) Sphenopalatine, (4) Greater palatine, and (5) Superior labial arteries.	90% of all epistaxis. Typically mild to moderate; triggered by digital trauma, dry mucosa, allergic rhinitis, foreign body, or cocaine.	Blow nose to evacuate clots $\rightarrow$ Topical vasoconstrictor spray (Oxymetazoline/Phenylephrine) $\rightarrow$ Direct cartilaginous compression x 15–20 min $\rightarrow$ Chemical cautery with Silver Nitrate $\rightarrow$ Anterior pack (Rapid Rhino/Merocel).
Woodruff's Plexus	Posterior-lateral wall of inferior nasal meatus. Confluence of the sphenopalatine artery (terminal branch of internal maxillary artery) and ascending pharyngeal artery.	10% of epistaxis. Severe, torrential, life-threatening arterial bleeding; occurs predominantly in elderly, hypertensive, or anticoagulated patients.	Direct compression fails. Posterior Nasal Balloon Tamponade (dual-balloon Rapid Rhino, Epistat, or 12–14 Fr Foley catheter) $\rightarrow$ Mandatory ICU/Telemetry admission $\rightarrow$ Interventional Radiology embolization or ENT surgical ligation of sphenopalatine artery.

2. The Nasal Trauma Emergency: Septal Hematoma

Following any blunt nasal trauma, sports collision, or motor vehicle accident, inspection of the nasal septum with a nasal speculum and bright light is mandatory. The nasal septal cartilage possesses no direct blood supply of its own; it derives 100% of its oxygen and nutrients via diffusion from the overlying tightly adherent perichondrium.

Trauma tears subperichondrial blood vessels, causing blood to pool between the cartilage and the perichondrium (Septal Hematoma). This physically strips the perichondrium off the cartilage. Within 24 to 72 hours, ischemia produces aseptic liquefactive necrosis of the septal cartilage or secondary septal abscess (S. aureus), leading to total structural collapse of the nasal dorsum (permanent 'Saddle-Nose' deformity).

Clinical Step	Physical Exam & Procedural Technique	Clinical Rationale
Examination	Inspect septum with speculum: look for a bilateral, asymmetrical, bluish/purple, boggy, fluctuant swelling obstructing the nasal airway	Palpate gently with a cotton-tipped applicator: a hematoma feels soft and compressible, whereas a deviated septum is hard and bony.
Immediate Drainage	Topical lidocaine/epinephrine anesthesia; perform a horizontal incision at the base of the hematoma using a #11 scalpel blade (or 18-gauge needle aspiration if tiny); express all clots	Restores immediate physical contact between the nutrient-bearing perichondrium and the ischemic cartilage.
Packing & Antibiotics	Place bilateral anterior nasal packing to compress perichondrium against cartilage; prescribe oral Cephalexin or Amoxicillin-Clavulanate	Prevents re-accumulation of the hematoma and secondary bacterial abscess formation.

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