Insertion of nasal tampon
From WardWiki - Foundation Doctor Helper
Insertion of nasal tampon requires some skills and knowledge of the nature of epistaxis but is very easily learned and well tolerated by patients. This article deals with the pre procedural care, the procedure and then post procedural care. Ensure training has been undertaken before doing any intervention unaided. This is an ideal DOPs under supervision.
- IV access and immediate ABC management as always in acute admissions.
- Ensure personal mucosal membrane protection against blood spray and assemble all equipment before donning gloves and apron as it becomes messy looking for equipment afterwards.
- After previous practice, use a nasal speculum to dilate up the affected nostril and use a light source for inspection under direct vision after spraying with lidocaine and phenylephrine to numb the area
- Use jankauer suction to removed adherent clot which can actually encourages further bleeding through various local mechanisms if this hinders a view. This rarely done but without such toileting the tampon can press against clot rather than occluding a target venule!
- Tampon opened but left absolutely dry - they soak up liquid readily and become floppy and useless
- Have Aquagel or KY jelly available to lubricate before insertion - insertion is extremely uncomfortable without this.
- Appreciate nasal skeletal anatomy differs markedly from that of the naso pharynx!!
- Have the patient sat up with head against a secure headboard. Explain the procedure and gain consent and trust. Hold the patient's head gently and push the lubricated dry tampon DIRECTLY BACK towards the occiput and not upwards towards the eyes. Do this is one firm and confident motion as it is uncomfortable and patients will fight. ASny delay soften the tampon.
- Stand back and see the tampon to be fully inserted with only the pulling tassle to be secured with tape to the face. "Walrus tusks" appear absurd and are ineffective.
- Insertion of nasal tampon can compromise the airway in theory, certainly if both nostrils are packed. This most only be done when one pack has failed but make no attempt to remove it if in place without called for senior help first - further intervention is more likely and repeated insertions traumatises the mucosa. This will make a rebleed more likely.
- Bilateral packing allows pressure from both packs to press against the bleeding vessel: There is a BONY septum between two SPONGES so no further explanation is required.
- All nose bleeds need packing in A&E - see article on epistaxis
- Patient can go home with a pack in - not true, these must be removed before discharge as must the venous cannula!
Post procedural care
- Patients are admitted onto an ENT or surgical ward with a bolster tied under the nose. This does not reduced bleeding but makes it apparent without dripping blood over the patient or the ward. A senior should be contacted and basic manoeuvres reapplied while waiting.
- Patients should have sips of cold water but avoid meals in case a rebleed occurs. No warm drinks or food for at least a day or two and likewise avoid hot baths and especially hot showers that will venodilate the nose and cause rebleed.
- Start co-amoxiclav 625mg TDS or an equivalent to prevent toxic shock and secondary haemorrhage if pack remains for longer than one day. Ask the registrar if unsure.
- A prospective, single-blind, randomized controlled trial of petroleum jelly/Vaseline for recurrent paediatric epistaxis.
Loughran S et al.
Clin Otolaryngol Allied Sciences, 2004 Jun;29(3):266-9.
- The 'walrus sign': an incorrect way to insert an anterior nasal pack.
Fu B, Emerg Med J. 2010 Jun 17.