• Persistent epistaxis localized anteriorly on the nasal septum that does not respond to digital pressure, topical vasoconstrictive agents, or cautery.

• Headlight.

• Nasal speculum.

• Frazier suction, 8F and 10F.

• Bayonet forceps.

• Yankauer suction.

• Tongue retractor/tongue blade.

• Absorbable topical vasoconstrictor (oxymetazoline).

• Expandable cellulose intranasal tampons.

• Antibiotic ointment (eg, bacitracin).

• Layered quarter-inch gauze with petroleum.

• Silver nitrate sticks.

• Hemostatic material.

• Cottonoid pledgets.

• 4% topical lidocaine or tetracaine hydrochloride.

• Mucosal abrasion.

• Septal perforation if excessively tight packing or bilateral cauterization.

• Neurogenic syncope during packing.

• As in any patient who is hemorrhaging, assess airway, breathing, and circulation first.

• Wear protective eyewear, gown, and gloves; maintain universal precautions.

• Once hemorrhage is controlled, instruct the patient against sneezing or coughing with his or her mouth closed, bending over, straining, or nose picking or blowing.

• Do not discharge a patient as soon as the bleeding stops; rather, observe him or her for at least 30 minutes to ensure that the patient is stable and the bleeding does not recur.

• Always look in the posterior oropharynx, behind the uvula, to ensure that blood is not dripping down and being swallowed.

• Do not cauterize both sides of the septum. Loss of the perichondrial layers on both sides of the septum can result in cartilage necrosis and septal perforation.

• If a patient has recurrent epistaxis, consider a neoplastic process, especially if bleeding always occurs on the same side.

• • Juvenile nasopharyngeal angiofibromas are highly vascular tumors arising in the nasopharynx that usually present as recurrent unilateral hemorrhage in pubescent males.

• Always provide systemic antibiotic coverage against Staphylococcus species.

• Severe epistaxis may require endotracheal intubation (for airway obstruction), cardiac monitoring and pulse oximetry, and vascular access (to administer intravenous crystalloid solution).

• Obtain a history, if possible, about digital nasal trauma, foreign bodies, hematologic disorders, medications, and nasal fracture.

• Obtain a blood count, clotting screen, and a sample for a cross-match.

• Inform the patient and parents that bleeding will be controlled in a stepwise fashion.

• If the patient is stable, have patient or assistant maintain firm digital pressure by pinching the nose closed with a gauze sponge.

• Consider sedation.