Anterior nasal packing

Nasal packing is a second-line therapy. See Epistaxis for more guidance. 

This page is for reference, not instruction: you should be shown how to do this by a senior before attempting it on your own. 

Preparation

Bleeding has not stopped despite first aid measures or direct therapy to the bleeding point. 

• Reassure the patient: it is disturbing to have blood continually dripping from your nose and into your throat; clots can give you a choking sensation. Have suction ready to help with this.

• Get an assistant

• Explain to the patient that you need to insert a nasal pack to stop the bleeding: it is uncomfortable to insert and will give them a headache once it is in. However, in the majority of cases, one pack stops the bleeding.

• Explain that, on inserting the pack, blood and clots will be pushed from the nose into the throat and they will need to be ready to spit it all out

• Don personal protective equipment including facial protection - patients cough and clear a lot of blood during nosebleeds

• Gather your equipment:

  • Nasal pack (Rapid Rhino® inflatable pack is preferred for patient comfort; Mercoel® or other tampon if this is not available)

  • Lubricant or sterile water (not saline) in a bowl as appropriate

  • Paper towels

  • Plenty of bowls/kidney dishes

  • A 10ml syringe if needed

Insertion

• If using a Merocel® or other dry sponge tampon:

  • You must put a suture through the tampon if it does not already have one: never put anything in the nose without leaving some way of pulling it out

  • Some people lubricate the tip of the tampon - use any lubricant

  • With your non-dominant hand, push up on the tip of the nose to see into the bleeding nostril

  • The space you are aiming for is medial and inferior; you should insert the pack against the septum and aiming in the same vertical plane as the ear lobe

  • In one motion, push the pack into the nose

  • The outer tip of the pack should sit next to the tip of the nose

  • The blood should wet the sponge and it will expand; if not, then you can encourage it with a drop of water

• If using an inflatable coated Rapid Rhino® or other pack:

  • YouTube clip: Rapid Rhino® Insertion NOTE This is a very useful animation of the insertion process but we don't endorse everything that is said, particularly discharging packed patients

  • Remove the pack from its sleeve

  • Place it in a bowl of sterile water for 30 sec (not saline - it inactivates the coating) until the white coating goes translucent

  • Do not leave in the water too long as the coating will fall off

    • With your non-dominant hand, push up on the tip of the nose to see into the bleeding nostril

    • The space you are aiming for is medial and inferior; you should insert the pack against the septum and aiming in the same vertical plane as the ear lobe

    • In one motion, push the pack into the nose

    • The outer tip of the pack should sit just inside the entrance to the nostril, so that the pack does not distend the nostril when inflated

    • Attach a syringe full of air and inflate until the pilot cuff is firm with some bounce

    • There is no set amount of air; the pilot cuff is your guide

    • Be wary that every time you attach a syringe to the Luer connection you open the valve - you may inadvertently deflate the pack so always double-check the pressure in the pilot cuff

Problems

Step 1: bleeding continues

• Is the pack sitting in the right place? Too far out = the walrus sign, where half the pack hangs over the upper lip; too far in = the outer tip of the pack is not visible

• Have you inflated enough, or has the pack pressure decreased? (Sometimes relaxation of the tissues can necessitate some supplemental inflation later).

Step 2: bleeding still continues

• Insert a pack on the contralateral side to provide counter-pressure

• Ensure the second pack is placed properly (see Step 1)

Step 3: bleeding still continues despite Step 2

• Discuss with an experienced ENT surgeon (experienced SHO or the middle grade)

• Consider posterior nasal packing and/or operative intervention

• Resuscitate in parallel

Afterwards 

• Full history and ABCDE assessment

• Inspect the oropharynx for continued brisk bleeding (there will be clots)

• Secure IV access and send blood including FBC, G&S and INR if indicated

• Document the vitals/observations; resuscitate if necessary; know that packing will raise blood pressure transiently

• Tape the suture or pilot cuff to the cheek and apply a nasal bolster (either a wad of gauze rolled up and stuck under the nose or a wad of gauze pulled through a length of finger-diameter Tubinette® which is then tied behind the head)

Page last reviewed: 9 December 2019