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Epistaxis - Management
How should I perform nasal cautery for acute epistaxis?

  • Consider nasal cautery in primary care if:
    • First aid measures have not worked, and
    • The appropriate expertise and facilities are available (good lighting, topical anaesthetic spray, and nasal speculum).
  • Prior to cautery
    • Ask the person to blow their nose to clear any clots and allow local anaesthetic to be applied. This may restart the bleeding.
    • Use topical local anaesthetic spray, preferably with a vasoconstrictor (such as lidocaine with phenylephrine — Co-phenylcaine®) prior to cauterizing the area. Wait for 3–4 minutes for the full effect. The vasoconstrictor may stop the bleeding, but once the effects have worn off the bleeding may start again.
  • To cauterize the bleeding point
    • Identify the bleeding point — it looks like a small red dot (less than 1 mm) and may not be actively bleeding.
    • Lightly apply the silver nitrate stick to the bleeding point for 3–10 seconds, until a grey-white colour develops.
      • Only cauterize one side of the septum to avoid nasal septal perforation.
      • Avoid touching areas which do not need treatment (for example facial skin, nasal alae).
  • After cautery
    • Dab the cauterized area with a clean cotton bud to remove excess chemical or blood.
    • Apply antibiotic ointment to the area.
      • Use Naseptin® (chlorhexidine and neomycin) cream first-line, applied to the nostrils four times daily for 10 days. Do not prescribe Naseptin® for people known to be allergic to peanut as it contains arachis oil (peanut oil).
      • If the person is allergic to peanut or neomycin, consider using mupirocin nasal ointment. This should be applied to the nostrils two to three times a day for 5–7 days.
    • Do not routinely pack the affected side.
    • Offer self-care advice.

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