Proceed down a stepwise fashion from pressure to vasoconstriction and topical devices to packing while considering risk factors that initiated the event. When initially visualizing, place the patient in the "sniffing position” with the patient slightly leaning forward. Use the speculum in the superior-inferior orientation to avoid septal trauma.  Evaluate for polyps, masses, trauma, and bleeding sources.
Can use 2 tongue depressors taped together on one end to create a makeshift device to pinch the nose
Attempt direct pressure for at least 20 minutes before moving to additional modalities
Generally only effective if acute bleeding has stopped and friable site of bleeding can be adequately visualized.  Less effective in acute hemorrhage
Usually Kesselbach's plexus for anterior bleeds
Leave on for a few seconds at most
Never cauterize both sides of the septum at one go (risk of septal perforation)
Video of silver nitrate cauterization.
Only use if all of the above have failed
Soak balloon with water (NOT saline) and insert along the floor of the nasal cavity
Inflate slowly with air (NOT saline or water) until the bleeding stops
Absorbent nasal tampon
Coat tampon with water-soluble antibiotics ointment and insert along floor of nasal cavity
If tampon has not expanded within 30s of placement, irrigate it in place with NS
Moisten three times per day with saline or water until removal
Apply ribbon gauze in accordion-like manner
90% of<unk>  is anterior.  Only consider posterior packing if all of the above have failed.
Associated with higher complication rates (pressure necrosis, infection, hypoxia)
Temporizing measure while awaiting ENT support
Consider nasal block as posterior packing is often very uncomfortable
All posterior packing should be accompanied by anterior packing
Rapid Rhino-rocket 7.5 cm +.  Also a dual chamber 9 cm packing available.  Inflate posterior then anterior baloons
Foley catheter with 30-cc balloon if dedicated posterior packing not available
Lubricate with topical antibiotic
Advance transnasally until visualized in posterior oropharynx
Inflate balloon with 7cc of saline; retract 2-3cm until lodged in post nasopharynx
Inflate with additional 5-7cc of saline to complete the pack
Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.
Temporizing measure while awaiting ENT support
*The NoPAC trial showed no difference in anterior packing rates with or without TXA. Higher quality evidence than prior studies.
500mg TXA applied to topical foam or non-absorbable packing and inserted into nares.
Injectable form of tranexamic acid (500mg/5mL), not the dilute form
Can consider adding Epinephrine to non-absorbable packing to assist with vasoconstriction
Injectable form of tranexamic acid (500mg/5mL), not the dilute form
Can consider adding Epinephrine to non-absorbable packing to assist with vasoconstriction
Epistaxis
Facial trauma
Syncope 
Coagulopathy
Syncope
Nasal tumor
Anaphylaxis
Juvenile Nasopharyngeal Angiofibroma 