Steps of the epistaxis management ladder
| Step 1 |
| The patient should sit with the upper part of the body tilted forward and the mouth open so that they can spit out the blood instead of swallowing. |
| Pinch all the cartilaginous part of the nose together between the thumb and index finger. Hold the nose for at least 5 minutes (timed by the clock). |
| Use Thudicum nasal speculum to examine the nose |
| Remove the blood clot using suction |
| Use cophenylcaine nasal spray |
| Examine thoroughly to identify the bleeding point |
| Use silver nitrate to cauterise the bleeding point |
| If bleeding point cannot be seen: nasal endoscopy and cautery using suction diathermy |
| If not competent to use nasal endoscope or bleeding point cannot be identified using endoscope, go to step 2 |
| Step 2 |
| Anterior nasal packing using Merocel, Rapidrhino, Vaseline gauze, or bismuth iodine paraffin paste |
| If not controlled, go to step 3 |
| Step 3 |
| Post nasal packing using Foley’s catheter, or Brighton, Simpson, or Bivona balloon |
| If not controlled, go to step 4 |
| Step 4 |
| Under general anaesthesia the following may need to be performed: |
| Examination of nose and cautery of bleeding vessel or |
| Tight nasal and post-nasal packing |
| Ligation of sphenopalatine artery or anterior ethmoidal artery or external carotid artery or internal maxillary artery |
| Angiography and embolisation |
| Submucous resection of septum |