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Chemical Cautery — Epistaxis Pregnancy: Topical application — acceptable for epistaxis treatment in pregnancy; epistaxis is common in pregnancy due to mucosal engorgement

Silver Nitrate

Brand names: Silver Nitrate Sticks (AVOCA 95%)

Adult dose

Dose: Apply cautery stick to bleeding point for 10–15 seconds after mucosal anaesthesia
Route: Topical (nasal mucosal application)
Frequency: Single application per bleeding vessel; maximum one nostril per session
Max: Single treatment session; do not cauterise both nostrils simultaneously (risk of septal perforation)
Chemical cautery of Little's area (Kiesselbach's plexus) for anterior epistaxis following local anaesthesia (lidocaine with adrenaline spray or pledgets). Effective for visible bleeding points after initial first aid. Do not apply to both sides of septum simultaneously — risk of avascular necrosis and perforation.

Paediatric dose

Dose: Single application to bleeding point application/kg
Route: Topical nasal
Frequency: Single application
Max: One nostril per session
Can be used in cooperative children (typically ≥8 years) under topical anaesthesia — younger children may require examination under anaesthesia (EUA)

Dose adjustments

Renal

Not applicable (topical application)

Hepatic

Not applicable

Paediatric weight-based calculator

Can be used in cooperative children (typically ≥8 years) under topical anaesthesia — younger children may require examination under anaesthesia (EUA)

Clinical pearls

  • Most common cause of epistaxis in children: Kiesselbach's plexus (Little's area) — anterior nasal septum; rich anastomosis of ethmoidal, sphenopalatine, and labial arteries
  • Silver nitrate cautery technique: achieve haemostasis first (pressure), apply lidocaine + adrenaline spray for vasoconstriction and anaesthesia, identify the bleeding point, apply cautery stick with 10–15s of sustained pressure
  • NEVER cauterise both sides of septum at same session — bilateral cautery interrupts blood supply to septum → avascular necrosis → perforation
  • EPISTAXIS: first-line is 20 minutes of continuous pressure (pinch soft part of nose — NOT bridge), head forward; cautery for recurrent anterior bleeding
  • Posterior epistaxis: cannot be cauterised directly — requires nasal packing (Merocel or Rapid Rhino) and urgent ENT review; sphenopalatine artery ligation or embolisation for refractory cases
  • Anticoagulated patients: reverse coagulopathy where possible before cautery; tranexamic acid nasal spray/topical can be used as adjunct

Contraindications

  • Active profuse bleeding (use nasal packing first)
  • Bilateral simultaneous application
  • Known silver allergy
  • Anticoagulated patients with uncontrolled INR — consider risks

Side effects

  • Temporary grey-black skin staining (argyria — resolves)
  • Pain (reduced with prior local anaesthesia)
  • Septal perforation (bilateral cautery)
  • Mucosal ulceration
  • Nasal crusting

Interactions

  • Hydrogen peroxide — can oxidise silver nitrate; do not use simultaneously

Monitoring

  • Haemostasis (primary endpoint)
  • Nasal septal integrity (follow-up)
  • Vital signs (significant epistaxis)

Reference: BNFc; BNF 90; ENT-UK Epistaxis Guidelines 2016; NICE CKS Epistaxis; Gifford and Edkins (Classic epistaxis anatomy). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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