Posterior bleeds should be referred to hospital. Assess duration, severity, frequency, timing related to activities, precipitating or aggravating factors, and possibility for foreign body. History should assist in determining whether the cause of epistaxis is due to mechanical trauma, medication-related, or an underlying condition (e.g., hypertension).

Consider referral to otolaryngologist if child under 2 years of age or patient has underlying disorders that predispose to bleeding. Assess for conditions that increase the risk of bleeding:

• tumors
• coagulation disorders
• recent trauma or surgery
• medications

Physical assessment:

• vital signs
• mental status
• airway and hemodynamic stability
• examination of the nose with speculum and light source

Note: Consider beginning this step while getting the health history.

Position the patient upright with head tilted forward. Hyperextension of the neck facilitates drainage of blood to the posterior pharynx and increases the risk of aspiration or emesis. 

Apply firm pressure to soft cartilaginous aspect of nose for 10-15 minutes. Do not remove pressure to assess if bleeding has stopped until 10-15 minutes has passed.

Encourage patient to spit blood or clots from posterior pharynx into kidney basin to reduce risk of aspiration or emesis.

May be done in conjunction with first-aid measures or if first-aid measures fail to achieve hemostasis alone. Directly spray or soak a cotton ball in a local vasoconstrictor such as Oxymetazoline or phenylephrine. Leave in place for 10-15 minutes and reassess.

Consider this step prior to examination of the nose as active bleeding obscures visualization. Soak cotton balls in lidocaine 2% with epinephrine. Insert soaked cotton balls into bleeding nostril and leave for 10 minutes. Upon removal, have patient gently blow nose to remove clots.

Do not perform nasal cautery if the bleed site cannot  be identified. Silver nitrate reacts to the mucosal lining to produce local chemical damage. Adequate anesthesia and vasoconstriction is required prior to cauterization (see Step 6).

•Apply firm pressure with silver nitrate stick to site of bleed for 5-10 seconds.
•Roll the tip of the silver nitrate stick on surrounding mucosa until dark gray eschar is formed (to cauterize feeding vessels).
•Remove excess silver nitrate to prevent staining of skin.
•Cauterize only one side of septum at a time to prevent risk of perforation due to decreased vascularization of cartilage.
•Apply topical antibiotic ointment to cauterized area for prophylaxis against infection and acts as topical barrier to prevent restart of bleeding.

Constant flow of blood in the posterior pharynx after packing suggests a posterior bleed. Perform anterior nasal packing if direct external pressure and nasal cautery are unsuccessful to achieve hemostasis  or if no obvious bleed site is visualized . Adequate anesthesia and vasoconstriction required prior to nasal packing (see Step 6).

Risks of nasal packing: failure to stop bleeding; toxic shock syndrome; blockage of nasal airway, sinus drainage or nasolacrimal duct; dislodgement of packing to oropharynx; nasovagal reflex (hypotension, bradycardia).
Use traditional gauze packing or commercially available nasal sponges or tampons (e.g., Rapid Rhino or Merocel – follow manufacturers instructions for use of commercially prepared products). Packing with gauze – use ribbon gauze impregnated with petroleum jelly. Use the Bayonet forceps to layer the ribbon gauze from bottom to top. Insert packing as posteriorly as possible.

Examine the posterior pharynx after packing inserted. Some blood behind the uvula is normal, and should be expected to stop. If continued bleeding occurs, this suggests a posterior bleed and referral is warranted.