History and Physical Exam Findings Differential Diagnosis Work up Management

Nosebleeds account for <1% of ED visits Children <10 years usually have mild

nosebleeds that originate anteriorly Incidence: 4 in 1,000 in children under

10y Increased incidence in cold weather (low

humidity) and with increased air pollutants

Children <2 years rarely get nosebleeds so suspect trauma or serious illness (1/10,000)

Age When did the

bleeding start? Unilateral or bilateral? How much blood loss? Blood in the mouth or

vomitus? What was done to

stop the bleeding? Trauma? Foreign body? Easy bruising or

bleeding?

PMHx? Nasal congestion,

discharge or obstruction?

Recent surgery? Family history? Medications? Associated

symptoms?› Headache or facial pain› Fever› Organomegaly› Hearing loss› Neck pain› Ecchymosis

Vital Signs! (especially BP and HR) Pallor Petechiae, bruising or gingival bleeding Hemotympanum Oropharynx exam Mucosal telangiectasias or hemangiomas Enlarged lymph nodes or organomegaly Icterus Visual acuity and extraocular movements with

history of facial trauma Pale or bluish nasal mucosa or boggy turbinates

CBC with smear Blood type and screen/cross-match PT PTT INR (for patients on anticoagulants) Von Willebrand factor if warranted CT or MRI if mass is suspected

Trauma› Nose picking!› Foreign body› Child abuse› NG tube› Nasotracheal intubation

Mucosal Irritation› Dry air› Allergic Rhinitis› Inhaled irritants/drugs› URI› Localized skin or soft

tissue infection

Anatomic› Septal deviation› Unilateral choanal

atresia with asymmetric airflow

Other› Increased venous

pressure from coughing

Medications› Aspirin› Ibuprofen› Anticoagulants› Valproic Acid

Tumors› Hemangioma› Juvenile NP

angiofibroma› Pyogenic granuloma› Rhabdomyosarcoma› NP carcinoma› Inverting papilloma

Granulomatous Disorders› Wegener’s› Sarcoidosis› Tuberculosis

Bleeding Disorders› Platelet disorders› Von Willebrand disease› Hemophilia› Inherited or acquired

coagulation disorders› Blood vessel disorders

(hereditary hemorrhagic telangiectasia aka Osler Weber Rendu syndrome)

Hypertension

Red macular and papular telangiectasias of the lips and tongue

Disorders Bleeding Time

Plts PT PTT Thrombin Time

Fibrinogen

Vasculopathies, CTD

Long Nl Nl Nl Nl Nl or ↑

Thrombocyto-penia

Long ↓ Nl Nl Nl Nl

Qualitative platelet abnormalities

Long Nl or ↓

Nl Nl Nl Nl

Hemophilia A (factor VIII deficiency)

Nl Nl Nl Long Nl Nl

Von Willebrand disease

Long Nl Nl Long Nl Nl

Disseminated Intravascular Coagulation

Long ↓ Long Long Long ↓

Adapted from UpToDate

Compression

0.05% oxymetazoline HCl (Afrin) or 0.25, 0.5 or 1% phenylephrine (20mcg/kg in children up to 25kg)

Side effects: headache, dizziness, dry nasal passage, nasal discharge, arrhythmia

Useful in patient with recurrent benign epistaxis

Chemical cautery with silver nitrate sticks Electrical cautery works well on a dry

surface Side effects: rhinorrhea and crusting;

ulceration and perforation

Composed of collagen-derived particles and topical bovine-derived thrombin

Commercially available as Floseal In a small prospective, randomized controlled trial

patients in the Floseal group were found to have better control of their epistaxis than patients in the anterior nasal packing group

Fibrin glue is another option that has fallen out of favor since matrix sealants are available

Apply topical anesthesia and nasal decongestant first if possible

Small risk of toxic shock syndrome associated with packing

Neither prophylactic antibiotics nor impregnation of nasal packing with antibiotic ointment eradicate nasal carriage or are proven to prevent toxic shock syndrome

Balloon catheter insertion

Embolization of the internal maxillary artery

Surgery (transnasal endoscopy and direct cautery or arterial ligation)

Initial evaluation should focus on respiratory and hemodynamic stability of the patient

History and physical should focus on the source of the bleeding

Lab evaluation is indicated for patient with frequent recurrent nosebleeds, severe nosebleeds that are difficult to control and patients with a personal or family history of bleeding disorders

CT or MRI is indicated if a mass is suspected Compression is the first plan of action to stop the bleeding Other techniques can be administered with the

involvement of ENT to stop the bleed

Messner, AH, et al. Evaluation of Epistaxis in Children. UpToDate. 2010

Messner, AH, et al. Management of Epistaxis in Children. UpToDate. 2010

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