Transcript Epistaxis In Children

History and Physical Exam Findings
 Differential Diagnosis
 Work up
 Management
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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)
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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?
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PMHx?
Nasal congestion,
discharge or
obstruction?
Recent surgery?
Family history?
Medications?
Associated symptoms?
› Headache or facial
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pain
Fever
Organomegaly
Hearing loss
Neck pain
Ecchymosis
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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
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Trauma
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Nose picking!
Foreign body
Child abuse
NG tube
Nasotracheal intubation
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› Septal deviation
› Unilateral choanal
atresia with asymmetric
airflow
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Dry air
Allergic Rhinitis
Inhaled irritants/drugs
URI
Localized skin or soft
tissue infection
Other
› Increased venous
Mucosal Irritation
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Anatomic
pressure from coughing
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Medications
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Aspirin
Ibuprofen
Anticoagulants
Valproic Acid
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Tumors
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› Hemangioma
› Juvenile NP
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Platelet disorders
Von Willebrand disease
Hemophilia
Inherited or acquired
coagulation disorders
› Blood vessel disorders
(hereditary hemorrhagic
telangiectasia aka Osler
Weber Rendu
syndrome)
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angiofibroma
Pyogenic granuloma
Rhabdomyosarcoma
NP carcinoma
Inverting papilloma
Granulomatous
Disorders
› Wegener’s
› Sarcoidosis
› Tuberculosis
Bleeding Disorders
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Hypertension
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Red macular and
papular
telangiectasias of
the lips and tongue
Disorders
Bleeding
Time
Plts
PT
PTT
Thrombi
n Time
Fibrinogen
Vasculopathies Long
, CTD
Nl
Nl
Nl
Nl
Nl or ↑
Thrombocytopenia
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 Long
disease
Nl
Nl
Long
Nl
Nl
Disseminated
Intravascular
Coagulation
↓
Long
Long
Long
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Long
Adapted from UpToDate
Compression
Vasoconstriction
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Cautery
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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
Matrix sealant
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Nasal packing
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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
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Balloon catheter
insertion
Embolization of the
internal maxillary
artery
Surgery (transnasal
endoscopy and
direct cautery or
arterial ligation)
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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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