• Ensure catheter is not pressing on the nose to avoid alar necrosis.

    • Patients with posterior packs require admission to hospital. The elderly and those with heart disease or COPD need supplementary oxygen.

    • Opiate analgesics to relieve discomfort and reduce elevated blood pressure due to posterior pack.

    • It may be necessary to ligate the sphenopalatine artery endoscopically, or occasionally internal maxillary artery and ethmoid arteries or perform endovascular embolisation of the internal maxillary artery, when packing fails to control life-threatening haemorrhage. Ligation of the external carotid artery is a last resort.

  • Complications of packing

    • Anosmia

    • Pack falling out and continued bleeding

    • Breathing difficulties and aspiration of clots

    • Posterior migration of the pack causing airway obstruction and asphyxia

    • Perforation of the nasal septum or pressure necrosis of cartilage

If elderly patients on warfarin present with epistaxis and signs of hypovolaemia such that rapid complete reversal of anticoagulation is appropriate - give prothrombin complex concentrate (less likely to cause fluid overload than fresh frozen plasma) and vitamin K (regimen depends on the indication of anticoagulation).

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