To a child, the nose is a fascinating part of the anatomy. When it is working well, they barely notice it. When it isn’t, it is the focus of much interest and anxiety. Additionally, it can be used as a piggy bank (ex, Nasal FB, Button Batteries), which makes it even more fun! Unfortunately, it also tends to stick out a bit and is prone to get struck (ex, Nasal Fracture). All this fascination, fun, and prominence can lead to bleeding, and as we know from our ability to use the nose as an expressway to access the bloodstream (ex, Intranasal Analgesia), the significant blood flow to the region can make nosebleeds look quite horrific. Let’s take a minute to consider the common, and also concerning, conditions associated with Epistaxis in Children:

Epistaxis: Basics

• Epistaxis is a common presenting complaint to the Emergency Department. [Shay, 2017; Damrose, 2006]
  • Affects ~30% of children 0-5 years of age
  • Affects ~50% of children 5 years and older
  • Occurs year long… not just in the winter… and may be worse during allergy seasons. [Shay, 2017]

• The nose has a rich blood supply:
  • >15% of total cardiac output goes to the brain alone… meaning a lot of blood goes to the head and neck.
  • Anteriorly – Kiesselbach plexus in the anterior nasal septum.
    • Majority of pediatric epistaxis is venous and arises from anterior plexus. [Patel, 2014]
  • Posteriorly – from the Sphenopalantine artery
    • Bleed much more profusely than anterior bleeds.
    • Can lead to airway compromise.

• Most often are minor bleeds and respond to conservative therapies. [Shay, 2017; Patel, 2014; Stoner, 2013; Damrose, 2006]
  • ~7% of children presenting to the ED require further interventions to control the epistaxis. [Shay, 2017]
  • The vast majority (93.5%) only required simple “procedure” to control anterior bleeding. [Shay, 2017]

Epistaxis: Considerations

The Common

• Rhino-Sinusitis
• Allergic rhinitis
• Viral-related rhinitis
• Retained foreign body
• Direct trauma

The Concerning

• Bleeding disorders (ex, Von Willebrand Disease or Hemophilia)
  • Unfortunately, family history or multiple symptomatic episodes do not reliably predict who will have a bleeding disorder or anemia. [Patel, 2014; Damrose, 2006]
  • Subspecialist (ex, ENT) often recommend screening for bleeding disorders [Patel, 2014; Damrose, 2006], but recall that these represent a possible selection bias.
  • There is a standardized “Pediatric Bleeding Questionnaire” that has shown some applicability in screening for children with increased risk for having a bleeding disorder. [Stokhuijzen, 2018]
  • In the ED, consider these issues if: [Damrose, 2006]
    • Recurrent epistaxis
    • “Severe”  or persistent / difficult to control epistaxis
    • Family history
    • Abnormal physical exam (ex, petechiae, splenomegaly)

• Neonplasm (ex, Juvenile Nasopharyngeal Angiofibromas)
  • Usually present with nasal obstruction and daily, unilateral epistaxis and are teenage males.
  • CT imaging is not recommended reflexively for epistaxis, but if findings concerning for mass, then CT of face/sinuses is imaging modality of choice. [Damrose, 2006]

• Non-Accidental Trauma [DeLaroche, 2017]
  • Sadly, we always have to worry about this.

Epistaxis: A “Reasonable” Approach

• Think Worst First!
  • Assess Airway, Breathing, Circulation
  • Have patient sit upright… cuz Gravity Works!

• Shed some light on the Scene!
  • Don’t just try to use your iPhone light!
  • Loupes with Headlight can be very helpful!
  • Nasal speculum also helps!
  • Look for Foreign Bodies, Masses, and Source of bleeding.

• Still Bleeding?
  • Gear Up! (put some coveralls on to protect yourself — and your clothes)
  • Have patient blow nose (or use suction) to get as much of the congealed blood out of the nasal cavity… allowing compression to be more effective.
  • Look (with your lighted loupes!) for obvious source – stop the bleeding:
    • Direct cautery
    • Topic TXA
    • Vasoconstictors
  • Can’t see obvious source? Compress the anterior septum.
    • May need to instruct parent/guardian on how to do this.
    • Remind them to compress anterior aspect of nose… not the bridge.
    • Hold for 10-15 minutes without interruption!
  • … Still Bleeding?
    • Nasal packing is, fortunately, not commonly needed in children.
    • If required, will likely need some medications to help patient be compliant… ketamine?
    • Anterior nasal packing
      • Can be applied and then removed after ~30 min to see if resolution…
      • Run risk of re-initiation of bleed though.
      • Can be applied with topical vasoconstrictors or TXA.
    • Posterior nasal packing
      • Requires hospitalization for airway monitoring
      • Consider empiric antibiotics to cover Staph and Strep
      • Consult ENT

• Not Bleeding Currently?
  • Awesome… but don’t get careless.
  • Look for obvious excoriation or source of bleeding.
  • Discuss management with compression if bleeding recurs.
  • Basic Home Supportive Care: [Patel, 2014; Damrose, 2006]
    • Limit digital trauma (or sticking other items up there!)
    • Limit blowing nose
    • Use nasal saline
    • Use moisturizing ointments
    • Topical antimicrobial ointments have also been advocated by some.

Moral of the Morsel

• Don’t just blame the kid’s finger. It is often multifactorial… URI lead to congestion which lead to discomfort which lead to finger in nose… all of which lead to bleeding.
• Odds are in your favor! Supportive care is likely all that is required.
• Be vigilant for the Concerning! Obtain a good History and do a thorough HEENT, Derm, and Lymph exam!
• Make sure you can see! Use the headlamp!

References