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
  Merocel nasal tampon without a suture - if you come across these, secure a suture to one end before use

 

Merocel nasal tampon without a suture - if you come across these, secure a suture to one end before use

  Rapid Rhino inflatable packs: 7cm (left) and double-balloon 9cm (right)

 

Rapid Rhino inflatable packs: 7cm (left) and double-balloon 9cm (right)

 

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 
Aim for the earlobe

Aim for the earlobe

 

  • 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

 

  Tip: The space you are aiming for is medial and inferior because the turbinates (IT and MT) are lateral and superior; a good landmark is to aim in the same vertical plane as the ear lobe as this will help you find the floor of the nose

 

Tip: The space you are aiming for is medial and inferior because the turbinates (IT and MT) are lateral and superior; a good landmark is to aim in the same vertical plane as the ear lobe as this will help you find the floor of the nose

 

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)
  What we used to use: a Cornish nasal bolster 

 

What we used to use: a Cornish nasal bolster 

 

 

Page last reviewed: 23 September 2017