may be useful for the apprehensive patient Care should be taken with patient positioning as well as with medication administration as brisk epistaxis may result in airway compromise in the supine or sedated patient Topical anesthesia and vasoconstriction of the nasal mucosa can be achieved with the use of an atomizer or cotton pledgets soaked with the desired agents ( Table 130.1 ) This will allow better visualization of the interior of the nose and may slow or even stop the bleeding In addition, the topical anesthetic will aid in minimizing the pain associated with instrumentation of the nose Prior to topical medication application, the patient should gently blow their nose to clear mucus, blood, and clot that may be present TABLE 130.1 EQUIPMENT—OTORHINOLARYNGOLOGIC PROCEDURES Directed light source (e.g., headlight, flashlight) Frazier section tip Nasal speculum Bayonet forceps Mucosal atomizer or cotton pledgets Topical vasoconstrictor (phenylephrine [0.25%, 0.5%], epinephrine [1:1,000]) Topical anesthetics (lidocaine [4%], ethyl chloride) Absorbable gelatin sponge (Gelfoam) Oxycel gauze (Surgicel) Silver nitrate sticks Tranexamic acid (100 mg in mL) Expandable sponge nasal pack (Merocel, Rhino-Rocket, Rapid Rhino) Vaseline gauze (0.5 × 72 in) Foley catheter (12 or 14 gauge with 30-mL balloon) Double balloon catheter Cuff (made of in length of suction tubing) Syringe (50 mL) Sterile saline solution Hoffman clamp (for Foley catheter) × gauze Alligator forceps Katz extractor FIGURE 130.19 Applying silver nitrate for epistaxis Insert the nasal speculum into the nose and open the blades widely, using a headlight or directed light source (i.e., flashlight or penlight) to illuminate the interior of the nose Most epistaxis originates from Kiesselbach plexus in Little’s area (the anterior septum), and this area should be examined first Suction any remaining clots or fresh blood gently with a Frazier suction tip on low-pressure wall suction to expose the source of hemorrhage Once the site of bleeding is located, apply the tip of a silver nitrate stick to it and roll it over the bleeding area for to 10 seconds ( Fig 130.19 ) Two or three sticks are often required to control an episode of epistaxis Once the bleeding has stopped, petroleum jelly or oxidized cellulose gauze (Surgicel) may be placed on the septum to stabilize the clot and protect the area from further trauma Refrain from cauterizing both sides of the nasal septum during the same encounter Vigorous bilateral cauterization may lead to septal perforation by depriving the underlying septal cartilage of its blood supply More recently, topical tranexamic acid (TXA) has been considered as an adjunct for managing severe epistaxis A cotton pledget is soaked in TXA (100 mg in mL) and inserted into the nostril of the bleeding site until no active bleeding is visible (approximately 10 minutes) However, further investigation is necessary to draw more definitive conclusions regarding its efficacy and safety in children NASAL PACKING—ANTERIOR AND POSTERIOR Indications Epistaxis recalcitrant to or not amenable to medical management or cauterization Complications Bacterial rhinosinusitis Toxic shock syndrome Nasal alar or columellar necrosis Septal ulceration or perforation Synechiae formation Hypoxemia or respiratory distress from sedation and nasal airway obstruction Procedure Anterior Pack Application of topical anesthesia, such as a 50/50 mixture of 4% lidocaine and oxymetazoline, may be considered prior to nasal packing Anterior packing can be performed using a variety of commercially available nasal tampons or as classically described using petroleum jelly or antibiotic ointment impregnated gauze Prior to insertion of packing, consider the use of an anxiolytic/amnestic or procedural sedation to minimize the pain and emotional trauma associated with the packing procedure in a pediatric patient Prepare the patient in the same manner as for cauterization, including the careful visualization of the nasal cavity and suctioning of active bleeding Mild anterior nasal bleeding can often be stopped with a small pack created out of absorbable material Examples include gelatin (Gelfoam), oxidized cellulose (Surgicel), and thrombin-gelatin products (Floseal, SurgiFlo) Although this type of material does not apply a lot of pressure to a bleeding site, it facilitates clotting, protects the nasal mucosa, and does not require removal Therefore, absorbable nasal packs are particularly useful for patients with bleeding disorders, with immunodeficiencies, or for patients who are unable to tolerate packing removal Nasal tampons and inflatable devices There are several commercially available products that all function by expansion when placed into the nasal cavity, thereby tamponading the site of bleeding A nasal tampon, such as Merocel, is inserted in a dry, compressed state along the floor of the nasal cavity ... procedural sedation to minimize the pain and emotional trauma associated with the packing procedure in a pediatric patient Prepare the patient in the same manner as for cauterization, including the careful