Clinical Practice Guidelines

Epistaxis

  • See also

    Resuscitation
    Analgesia & Sedation

    Key Points

    1. Usually due to minor trauma or friable nasal mucosa
    2. Try simple measures to stop bleeding first
    3. Effective resuscitation is vital if circulation is compromised
    4. Seek early ENT opinion if bleeding is severe or difficult to stop

    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.

    Little's area

      

    Assessment

    History

    Consider underlying diagnosis / cause if:

    • 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

    Examination

    • Airway - assess for airway compromise (e.g. if facial trauma)
    • Breathing
    • Circulation
    • assess site of bleeding (if able)

    Management

    Investigations

    • often not needed in epistaxis unless positive history for above
    • if circulation compromised or probable history of underlying bleeding diathesis: check haemoglobin, haematocrit, group and hold / crossmatch, coagulation screen

    Treatment

    If signs of shock refer to Resuscitation Guideline

    Try simple measures first to stop the bleeding:

    • child should be sitting up with head in comfortable position (e.g. on parent's lap)
    • tilt head forward slightly
    • apply continuous pressure on the anterior portion (cartilage) of the nose with thumb and forefinger for 10 minutes (see diagram below)
    • child should breathe through the mouth and allow any blood to run in to a kidney dish rather than swallowing

    Simple measures to stop bleeding

    If this stops the bleeding, the child can be discharged. See discharge information

    If persistent bleeding:

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

    Cautery

    Consult a senior doctor if cautery is required.

    Do not attempt under the age of four years as it is unlikely the child will cooperate.

    Cautery procedure video

    • haemostasis must be achieved first via pressure / vasoconstrictors
    • have the child lying down (sedation not recommended due to risk of inhalation of clots or packing / local anaesthetics)
    • use Cophenylcaine spray (not under 2 years old), or topical lignocaine 1% with adrenaline 1:100,000 (0.3ml/kg max 3mg)
    • allow time for the local anaesthesia to work (can take up to 10 minutes for the spray, may require initial spray in to nose followed by spray on to cotton ball applied directly to bleeding site)
    • have a good headlight (use the Lumiview if available)
    • chemical cautery can be achieved by applying the tip of the silver nitrate stick to the bleeding site
    • overzealous cautery can result in ulceration and perforation
    • silver nitrate sticks may not require moistening with water. Excessive moistening may lead to silver nitrate solution running and staining the nares

    If these measures stop the bleeding, see discharge information below.

    If these measures fail, nasal packing may be required.

    Anterior nasal packing

    If site of bleeding known, insert unilateral anterior nasal pack.

    Bilateral anterior packing or any posterior packing should not be attempted without ENT consultation.

    The easiest form of anterior packing is to use a prefabricated nasal tampon e.g. Merocel®. 

    • 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

    If unilateral anterior packing stops the bleeding, discharge home and review in 48 hours. Moisten with saline prior to removal and provide discharge information.

    Consider consultation with local paediatric team when:

    Discuss with ENT if:

    • severe or persistent bleeding
    • bilateral anterior packing or posterior packing is required

    Consider transfer when:

    Children requiring care beyond the level of comfort of the local healthcare facility.

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Consider discharge when:

    Bleeding has stopped.

    Parents provided education on ongoing management and management of recurrence (see below).

    Discharge information

    • if simple measures are used to stop bleeding discharge with education on management at home and preventative measures (no nose blowing for one week, no nose picking)
    • if there is crusting and the mucosa appears infected, consider treatment with a topical antibiotic ointment (e.g. Mupirocin)
    • if dry cracked mucosa contributing, petroleum based gel (e.g. Vaseline)* should be applied daily in the morning until healing. Use twice daily for one week if cautery or packing was required
    • for frequent recurrences consider ENT review as an outpatient

    * There is a risk of chemical pneumonitis if petroleum based gel is inhaled - long term use should be avoided.

    Parent Information sheet

    Nosebleeds

    Last Updated March 2019