Chemical cautery with silver nitrate is performed for mild active bleeding or after bleeding has stopped and prominent vessels identified. Only one side of the septum is cauterized to reduce the risk of perforation. Optimal results occur when the cauterization is started on the surrounding tissues and then upon the source itself. The silver nitrate stick should be rolled over the area for 5-10 seconds until a grey eschar forms, avoiding prolonged use or too much pressure. Silver nitrate works best on a relatively bloodless surface as any blood flow will wash away the silver nitrate before it can act.

An alternative to cautery is NosebleedQR, a non-prescription powder of hydrophilic polymer and potassium salts, which rapidly forms a crust once applied to a bleeding lesion. The powder is loaded onto an applicator swab and applied firmly to the site allowing it to interact with the blood directly. This is followed by pinching the nose or maintaining direct pressure for 15-20 seconds. Cost is less than $10.

Nasal packing has been the next step for persistent bleeding if cautery is unsuccessful or if no obvious site on the septum is visible. Commercially available balloons are simple to use, rapid, and quite effective for anterior bleeds.

The Rapid Rhino is composed of an inflatable balloon coated with a carboxymethylcellulose hydrocolloid compound that acts as a platelet aggregator and also forms a lubricant upon contact with water. After soaking in a basin of sterile water for 30 seconds, the device is inserted along the septal floor and parallel to the hard palate until the fabric ring is well within the naris. Using a 20-mL syringe, inflate the device with air, stopping when the pilot cuff becomes rounded and feels firm when squeezed, similar to placement of an endotracheal tube. Different sizes are available—a 4.5 cm for children, 5.5 cm for anterior epistaxis, and 7.5 cm for posterior bleeds.

Advantages of the Rapid Rhino over traditional compressed foam products include ease of insertion, patient comfort, and minimal rebleeding upon removal.³ Nasal packs are reported to stop bleeding in 60%-80% of cases refractory to pressure and vasoconstrictors. The pack is left in place for 72 hours. At the follow-up visit, the nose is re-inspected, ideally by an otolaryngologist, to exclude any organic pathology that may have accounted for the bleeding.

A variety of hemostatic compounds that do not require extraction are useful for patients with or without coagulopathies. Oxidized regenerated cellulose (Surgicel or Oxycel) and absorbable gelatin foam (Gelfoam) increase clot formation by encouraging platelet aggregation, can conform to irregular surfaces, and provide some degree of tamponade. Place the product directly over the bleeding site.