EM@3AM: Pediatric Epistaxis

Authors: Jawad Arshad, MD (EM Resident Physician Kaiser / San Diego, CA) and Kristy Schwartz, MD/MPH (EM Attending Physician, UCSD / San Diego, CA) // Reviewed by Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


A previously healthy 2-year-old boy with no past medical history presents to the emergency department after having 3 days of recurrent nosebleeds. He had no adverse birth history and is up to date on his vaccinations. The patient’s mother denies any known trauma and the patient denies picking his nose. In addition, he has no fever, headaches, nausea, hematuria, dysuria, vision changes, or known toxic ingestions. The patient is uncircumcised. The patient’s uncle previously had issues with bleeding after surgery.

Vital Signs are HR 120, RR 30, BP 120/70, and O2 Saturation of 99% on room air.  Physical exam is remarkable for ongoing epistaxis via bilateral nares.

Initial laboratory results include white blood cell count 10,900/μL, hemoglobin 10.9 g/dL, platelet count 200 × 103/μL, APT 45.6s.

What’s the diagnosis, and what are your next steps in evaluation and management?


Answer: Epistaxis caused by Hemophilia

Epidemiology:

  • Epistaxis affects up to 30% of all children between ages 0-51 and accounts for 1 in every 200 ED visits.2
  • Over 50% of children age <10 years have at least one nosebleed.1
  • Incidence is bimodal, affecting children under 10 years and geriatric patients most frequently.
  • Occurs more commonly during winter and allergy seasons3
    • Increased epistaxis when weather is either warm or cold, or when there is low humidity.4

 

Anatomy:

  • As a highly vascular structure, the nose can efficiently humidify, filter, and warm air.
    • Unfortunately, this predisposes it towards bleeding.5
  • The majority of pediatric epistaxis is from the venous system.
    • Anterior nose supplied by Kiesselbach plexus (anastomosis of terminal vessels of internal and external carotid arteries).6
    • Posterior portion supplied by Sphenopalantine artery, which tends to bleed more profusely than Kiesselbach plexus.6
  • Profuse bleeding, especially in the posterior nose, can lead to airway compromise.6

 

Clinical Presentation:

  • Local trauma
    • Rhinotillexis refers to nose picking with one’s finger and is a common cause of epistaxis in children.
    • Blunt head/facial trauma
      • May cause significant bleeding due to excellent vascularity of face/nose.
      • Non-accidental trauma should be considered.9
    • Foreign body
      • Suspect when epistaxis is unilateral and has malodorous discharge from the nostril.7
      • Foreign bodies are often found below the inferior turbinates.
    • Bleeding Disorders such as Von Willebrand’s Disease or Hemophilia
      • Recurrent epistaxis, often bilateral
      • Prior history of easy bruising/bleeding (i.e. after circumcision)
      • Family history of epistaxis or frequent bruising/bleeding
    • Neoplasm
      • Nasal obstruction
      • Unilateral epistaxis
      • Tend to be teenage males9

 

Evaluation:

  • Majority of epistaxis does not involve acute airway compromise or hemodynamic instability.10
  • Exam should include assessment of airway stability, general appearance, vital signs, and mental status.10
  • Provide hemodynamic resuscitation or acute airway interventions, if needed.9
  • Inquire about previous episodes of epistaxis and what methods have been attempted to control bleeding.10
  • Consider labs for patients with recurring bleeding including CBC, coagulation studies.

 

Treatment:10-16

  • Most epistaxis resolves with appropriate placement of nasal pressure.
    • Have the child tilt their head forward and apply continuous pressure to anterior nasal alae for 5-10 minutes.10
  • Children should breathe through their mouth and have a receptacle to allow for blood collection.
  • If this does not resolve bleeding, attempt vasoconstrictors in the nostrils after which you can hold pressure.
    • Oxymetazoline (Afrin): 1-1.5 ml in affected nostril
    • Phenylephrine 1% – 2-3 sprays in each nostril
    • Perform this with good lighting
    • Continue anterior pressure technique
    • Allow 10-15 minutes for optimal vasoconstriction, then reassess
  • If neither aforementioned treatment leads to cessation of bleeding, cautery may be attempted if the source of bleeding can be visualized.11
    • With the child lying down and appropriately restrained, apply tip of silver nitrate stick to area of bleeding, then neutralize with 1-2 drops of saline.
  • If bleeding site is known and there is still no resolution with above techniques, anterior nasal packing should be considered.12-14
    • Use commercially available nasal tampon (i.e. Rhino Rocket®), if available, for children who are old enough that it will pass easily. (Figure 1)
    • In younger children or those whose nasal passages are too small for commercially available products, create your own nasal tampon.
      • Roll 2×2” or 4×4” gauze or surgical gel foam lengthwise
      • Soak it in saline or vasoconstrictor
      • Guide into nasal passage via a long-tipped cotton applicator
    • If posterior bleeding site is suspected, apply posterior packing.14-16
    • The area of bleeding is relatively inaccessible.
    • Analgesia will be required for patients with posterior packing and balloon catheters.
    • Describe methods here (foley bulb is probably most commonly used).
    • Complications to watch out for include sinus obstruction, patient discomfort, and pressure necrosis of the posterior structures.

  • If there is a need for bilateral anterior packing or for posterior packing, ENT should be consulted for the patient.
  • Though not FDA approved specifically for epistaxis in children, consider nebulized, pledget soaked, or IV tranexamic acid (TXA) in patients with ongoing severe bleeding or hemodynamic compromise.18,19
  • Medical management should be considered for hematological deficiencies if appropriate such as factor replacement for hemophilia.20
  • Blood transfusion, if necessary, for those with hemodynamic compromise or severe hemorrhagic anemia.
  • Consult ENT or other institutionally determined surgical team for operative management if all other treatment options fail.

 

Disposition:

  • For the majority of patients, using techniques noted above treat epistaxis easily in the ED.
  • If the patient is hemodynamically stable with no airway compromise and no evidence of significant blood loss, consider discharge once the bleeding has resolved.
  • For persistent or severe bleeding, especially in the context of hemodynamic instability or airway compromise, consult ENT.21

 

Pearls:

  • Supportive care is the most likely course of action for epistaxis.
  • Consider a variety of differentials ranging from simple epistaxis caused by humidity changes to hematologic deficiency based on clinical context.
  • Progression of treatments for epistaxis: anterior alae pressure, use of vasoconstrictor, cautery, nasal packing, ENT consultation.

 

From Dr. Katy Hanson at Hanson’s Anatomy:


Further Reading:

FOAM:

  1. http://www.emdocs.net/epistaxis-in-children/
  2. https://www.aafp.org/afp/2014/0715/p105.html
  3. http://www.emdocs.net/r-e-b-e-l-em-hemophilia-whats-bloody-funny/

References:

  1. Damrose Damrose JF, Maddalozzo J. Pediatric Epistaxis. The Laryngoscope. 2006;116(3):387-393. doi:10.1097/01.mlg.0000195369.01289.9b
  2. Pallin DJ, Chng Y-M, Mckay MP, Emond JA, Pelletier AJ, Camargo CA. Epidemiology of Epistaxis in US Emergency Departments, 1992 to 2001. Annals of Emergency Medicine. 2005;46(1):77-81. doi:10.1016/j.annemergmed.2004.12.014
  3. Shay S, Shapiro NL, Bhattacharyya N. Epidemiological characteristics of pediatric epistaxis presenting to the emergency department. International Journal of Pediatric Otorhinolaryngology. 2017;103:121-124. doi:10.1016/j.ijporl.2017.10.026
  4. Akdoğan MV, Hızal E, Semiz M, et al. The Role of Meteorologic Factors and Air Pollution on the Frequency of Pediatric Epistaxis. Ear, Nose & Throat Journal. 2018;97(9). doi:10.1177/014556131809700901
  5. Stoner MJ, Dulaurier M. Pediatric ENT Emergencies. Emergency Medicine Clinics of North America. 2013;31(3):795-808. doi:10.1016/j.emc.2013.04.005
  6. Patel N, Maddalozzo J, Billings KR. An update on management of pediatric epistaxis. International Journal of Pediatric Otorhinolaryngology. 2014;78(8):1400-1404. doi:10.1016/j.ijporl.2014.06.009
  7. Epistaxis – Cautery – Packing – Ligation. TeachMeSurgery. https://teachmesurgery.com/ent/nose/epistaxis/. Published May 16, 2020. Accessed February 11, 2021.
  8. Reddy IS. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and the therapeutic measures. Postgraduate Medical Journal. 2001;77(905). doi:10.1136/pmj.77.905.215a
  9. Delaroche AM, Tigchelaar H, Kannikeswaran N. A Rare But Important Entity: Epistaxis in Infants. The Journal of Emergency Medicine. 2017;52(1):89-92. doi:10.1016/j.jemermed.2016.07.079
  10. Bernius M, Perlin D. Pediatric Ear, Nose, and Throat Emergencies. Pediatric Clinics of North America. 2006;53(2):195-214. doi:10.1016/j.pcl.2005.10.002
  11. Béquignon E, Teissier N, Gauthier A, et al. Emergency Department care of childhood epistaxis. Emergency Medicine Journal. 2016;34(8):543-548. doi:10.1136/emermed-2015-205528
  12. Reddy IS. Foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnostic pointers, and the therapeutic measures. Postgraduate Medical Journal. 2001;77(905). doi:10.1136/pmj.77.905.215a
  13. Lambert E, Friedman EM. Epistaxis. Management of Bleeding Patients. 2021:239-246. doi:10.1007/978-3-030-56338-7_25
  14. Burton MJ, Doree C. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database of Systematic Reviews. 2004. doi:10.1002/14651858.cd004461.pub2
  15. Mulbury PE. Recurrent Epistaxis. Pediatrics in Review. 1991;12(7):213-216. doi:10.1542/pir.12-7-213
  16. Baugh TP, Chang CWD. Epidemiology and Management of Pediatric Epistaxis. Otolaryngology–Head and Neck Surgery. 2018;159(4):712-716. doi:10.1177/0194599818785898
  17. Rhino Rocket® with Applicator. Summit Medical, LLC. https://shippertmedical.com/products/rhino-rocket-with-applicator. Accessed February 3, 2021.
  18. Tranexamic acid to help treat nosebleeds (epistaxis). https://www.cochrane.org/CD004328/ENT_tranexamic-acid-help-treat-nosebleeds-epistaxis. Accessed February 11, 2021.
  19. WH. Dzik MAB, H. Shakur IR, JJ. Morrison JJD, et al. Tranexamic acid in pediatric trauma: why not? Critical Care. https://ccforum.biomedcentral.com/articles/10.1186/cc13965. Published January 1, 1970. Accessed February 11, 2021.
  20. R.E.B.E.L. EM – Hemophilia: What’s so Bloody Funny? emDOCs.net – Emergency Medicine Education. http://www.emdocs.net/r-e-b-e-l-em-hemophilia-whats-bloody-funny/. Published May 5, 2017. Accessed February 2, 2021.
  21. Burton MJ, Doree C. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database of Systematic Reviews. 2004. doi:10.1002/14651858.cd004461.pub2

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