Epistaxis

  • See also: Resuscitation
    Analgesia & Sedation

    Background

    Epistaxis in children is usually from Little's area (see diagram), which is on the septal wall anteriorly.  The bleeding is usually venous, is of brief duration and is often recurrent.

    The two most important factors in childhood epistaxis are:  

    • Minor trauma - from nose picking, rubbing, sneezing, coughing or straining
    • Friable nasal mucosa - from upper respiratory tract infection, drying of mucosa, intranasal steroids

    Rarer causes include foreign bodies, nasal polyps, bleeding diatheses, vascular malformations, and nasopharyngeal tumors.

    epistaxis pic

    Assessment

    History:

    • recurrent or frequent episodes
    • easy bruising
    • past history of bleeding after surgical challenges (eg dental extractions, tonsillectomy, circumcision)
    • family history of bleeding, menorrhagia, recurrent epistaxis
    • medication eg NSAID's, nasal sprays, nasal medication

    Management

    Resuscitation and Assessment:

    Airway - assess for airway compromise (e.g. if facial trauma)
    Breathing
    Circulation - Group and Hold/ Crossmatch,  FBE, Clotting

    Stop the bleeding:

    • if signs of shock refer to Resuscitation guideline
    • try simple measures first
    • consider early ENT opinion if severe or difficult to stop

    Simple measures: 

    • continuous pressure on the anterior portion of the nose for 10 minutes 
    • squeeze nose between thumb and side of index finger (see photo)  
    • patient should be sitting up with head in comfortable position
    • if this stops the bleeding, patient can be discharged with education
    • if dry cracked mucosa contributing, petroleum gel (eg Vaseline) should be applied until healing  
    • for frequent recurrences consider an ENT review as an outpatient

    Persistent Bleeding:

    • often due to inadequate treatment/pressure 
    • determine the site of bleeding
    • if bleeding remains uncontrolled, cautery or packing  may be required 
    • consult senior doctor if performing cautery

    Cautery:

    • haemostasis must be achieved first via pressure/vasoconstrictors
    • chemical cautery can be achieved by applying the tip of the silver nitrate stick to the small area around the bleeding site
    • overzealous cautery can result in ulceration and perforation

    Hints for nasal cautery

    • Never attempt under the age of four years, as it is unlikely that the child will co-operate.
    • Allow time for anaesthesia to work
    • Have the child lying down
    • Have a good headlight (use the Lumiview if available).
    • Silver nitrate sticks may not require moistening with water.  Excessive moistening may lead to silver nitrate solution running and staining the nares
    • Give instructions about:
      • Continue petroleum gel b.d. for one week
      • No nose blowing for one week
      • No nose picking

    If these measures fail, nasal packing may be required:

    • If site of bleeding is known, insert unilateral anterior nasal pack
    • For persistent bleeding, urgent ENT consultation is warranted
    • Bilateral anterior packing or any posterior packing should not be attempted without ENT consultation

    Anterior nasal packing

    The easiest form of anterior packing is to use Xomed Merocel® Nasal Tampons.  Coat with water soluble gel, grasp the string end with fingers or forceps.  Gently and quickly insert along the floor of the nasal cavity until the string reaches the nose.  If packing hasn't expanded in 30 seconds, irrigate with 10ml of saline or water.  Tape the string to the nose and trim ends.

    epistaxis pic2

    Follow up

    • Epistaxis controlled by simple measures can be followed up by local doctor
    • Children who have had unilateral anterior packing should be reviewed in the Emergency Department or by ENT within 48 hours.
    • Merocel® Nasal Tampons should be moistened with normal saline for ease of removal.