A surprisingly common complaint that I deal with in the pediatric ED is epistaxis. While I find that many cases come down to worried parents who haven’t applied appropriate measures to get the bleeding to stop, I still figured it was a good topic to review since most residents are going to run across a blood nose at some point.
The lifetime incidence of epistaxis ~60% – though I suspect that may be an underreporting bias. Up to 64% of children younger than 15 years old have had at least one nosebleed. Greater than 80% of epistaxis is anterior, and that’s good, because life-threatening epistaxis is usually from posterior nasal or nasopharyngeal sources. Fortunately this is very rae in children. The most common etiology is local irritation – with digital trauma being an underreported cause. Other causes include recent URI or sinus infection, foreign bodies, trauma, post-surgery, excessively dry air (e.g. children who use masks or nasal cannulae), overuse/inappropriate use of nasal sprays (e.g. steroids or oxymetolazone(Afrin)), coagulation disorders and hematologic malignancies and juvenile nasopharyngeal angiofibromas (JNA) – a benign tumor that occurs in adolescents..
Anterior vs Posterior
Anterior nosebleeds arise from Kesselbach’s plexus which is fed by branches of several local vessels (see below diagram). These small vessels bleed easily when friable/irritates, but stop bleeding readily because they are small. Posterior nosebleeds come from larger less accessible vessels from the lesser-known Woodruff’s plexus, a venous plexus situated in the posterior part of inferior meatus.
ED Evaluation & Management
If the bleeding has already stopped you are done – mostly. In the ongoing bleed, especially one that is profuse take a focused history. posterior bleeds can dump a lot of blood into the mouth, and the potential for airway compromise is certainly there. Inquire about laterality and frequency, as well as a history of recent surgery. If symptoms include nasal congestion and anosmia this might be a tumor (JNA in male adolescents). Management will be discussed according to the following scenarios;
Not bleeding anymore
You’re done. Spend time educating on what to do if it recurs and consider three days of bid Afrin. Saline nasal spray or humidification can also help decrease the risk of recurrence. Despite parental insistence, you usually do not need a Hematology consult if the bleed is an isolated episode and there is no personal or family history of epistaxis or easy bleeding/bruising.
Still bleeding, but not too much
Management, as you’d expect, is typically conservative if bleeding is minimal. Visual inspection (otoscope) is generally fine, and a nasopharyngeal scope may be impractical if bleeding is severe or patient is uncooperative. Suction or have the patient blow their nose to remove clots, apply two sprays of Afrin in the affected nostril(s), then hold direct pressure compressing both alae for 10-15 minutes. Have the patient lean forward, so that they don’t get a stomach full of blood – which is something that stomachs do not like. If they are still bleeding then hold pressure for 15-30 more minutes. If still bleeding you can consider silver nitrate cautery, or packing. If this is a recurrent bleed, or the blood loss is significant consider coags and a PFA-100, though the yield is pretty low, and the likelihood that you’ll need to give products is slim. For bleeds that still won’t quit, nasal packing or other adjuncts (Surgicel, Floseal) may be warranted. Posterior packing may warrant sedation and or intubation as this is a very uncomfortable procedure.
Anterior packing options include Merocel, Rhino Rocket, Anterior Rapid Rhino
Posterior packing options AP Rapid Rhino, Epistat catheter
Here are some videos of different types of packing
Bleeding a lot, and in shock
As always start with the ABCs. Two big IVs, get labs including a type and screen. Give O negative if you absolutely, positively can’t wait for your labs. If you are worried that there is a risk of aspiration, secure the airway via rapid sequence intubation prior to dealing with the nose. Call ENT soonish. Packing is an option here as well, and it goes without saying that a child that needs packing (especially posterior) should probably be admitted. Failure to control epistaxis with formal packing warrants surgical or IR intervention.