What are the indications for cauterization in the management of nosebleeds, and what techniques are recommended?

Indications for cauterization in the management of nosebleeds:

• Cautery is considered if bleeding does not stop after 10–15 minutes of applying nasal pressure and first aid measures have failed.
• It should only be performed if the bleeding point can be clearly identified, typically within Kiesselbach's plexus, appearing as a small red dot less than 1 mm, which may or may not be actively bleeding.
• The procedure should be tolerated by the patient, generally suitable for adults and older children but not recommended for younger children under 4 years old.
• Appropriate expertise and facilities must be available in primary care, including good lighting, topical anaesthetic spray, and a nasal speculum.

Recommended techniques for nasal cautery:

• Ask the patient to blow their nose to clear clots before applying local anaesthetic; this may restart bleeding.
• Use a topical local anaesthetic spray combined with a vasoconstrictor (e.g., lidocaine with phenylephrine such as Co-phenylcaine®) and wait 3–4 minutes for full effect.
• Identify the bleeding point precisely and apply a silver nitrate stick lightly to the site for 3–10 seconds until a grey-white colour develops.
• Only cauterize one side of the nasal septum to avoid septal perforation and avoid touching non-bleeding areas such as facial skin.
• Avoid cauterizing a large mucosal area to prevent excessive tissue injury.
• After cautery, dab the area with a clean cotton bud to remove excess chemical or blood.

Nasal cautery is recommended as a first-line treatment over nasal packing when the bleeding site is identified, as it is better tolerated and more effective, although evidence quality is low.

If cautery is ineffective or the bleeding point cannot be seen, nasal packing or referral to secondary care should be considered.

Patients should be advised to avoid activities that increase re-bleeding risk for 24 hours post-procedure, such as nose blowing, picking, heavy lifting, strenuous exercise, lying flat, and consuming alcohol or hot drinks.

If bleeding restarts and does not respond to first aid, urgent medical advice should be sought.