Nejm 2009;360:784; Wm Maxwell 1/98

Rx:Prevent w short-term topical premarin cream bid

• 1^st, direct pressure, pinching nasal septum
• 2^nd, pack nose w cotton strips soaked w topical anesthesia + vasoconstrictor (4% cocaine does both) or simply OTC vasoconstrictor (Afrin, Zicam)
• 3^rd, cauterize w silver nitrate or electric cautery
• 4^th, pack, leave anterior packs in place 3 d, posteriors 5 d, w
• Vaseline strip gauze anteriorly, or Merocel pack, or Gelfoam, or Rapid Rhino
• Balloon pack (Nozstop, etc), in anterior nose and in nasopharynx
• Posterior pack or Foley catheters

Refer to ENT if bleeding persists for internal maxillary artery ligation