Table 1

 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