Pediatric emergency medicine trisk 143

Local predisposing factors
Trauma, direct and picking
Nonaccidental in the preambulatory child
Local inflammation:
Acute viral upper respiratory tract infection (common cold)
Acute infectious illnesses accompanied by nasal congestion: measles,
infectious mononucleosis, acute rheumatic fever
Bacterial rhinitis/sinusitis (Staphylococcal aureus )
Allergic rhinitis
Rhinitis sicca
Foreign body
Nasal polyps (cystic fibrosis, allergic, generalized)
Staphylococcal furuncle
Drugs: Nasal corticosteroids
Vascular malformations (telangiectasias as in Osler–Weber–Rendu disease,
hemangiomas)
Juvenile angiofibroma a
Other tumors, granulomatosis, ectopic nasal tooth (rare) a
Systemic predisposing factors
Systemic lupus erythematosus (SLE)
Congenital syphilis
Hematologic disorders a
1. Platelet disorders
Quantitative: idiopathic thrombocytopenic purpura, leukemia, aplastic
anemia
Qualitative: von Willebrand disease, Glanzmann disease, uremia
2. Hemophilias
3. Clotting disorders associated with severe hepatic disease, disseminated
intravascular coagulation (DIC), vitamin K deficiency
Drugs: aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin,
valproic acid, rodenticide

Vicarious menstruation
Hypertension a


Arterial (unusual cause of epistaxis in children)
Venous: superior vena cava syndrome or with paroxysmal coughing seen in
pertussis and cystic fibrosis
a Life-threatening

condition.

TABLE 26.2
COMMON CAUSES OF EPISTAXIS
Trauma (acute blunt and recurrent, minor)
Foreign body
Allergic rhinitis
Rhinitis sicca
Viral rhinitis
While working to control bleeding, one should also seek its origin. A posterior
bleed is rare in children, but is important to identify since these bleeds are often
harder to control and warrant more intensive therapy. Blood seen in the
oropharynx, blood in both nares, difficulty controlling bleeding despite adequate
anterior pressure, and a normal anterior examination are more characteristic of a
posterior nasal bleed but can be found with an anterior causative site. Bleeding
seen at any site in a child who has undergone tonsillectomy and/or
adenoidectomy in the preceding 1 to 2 weeks is concerning and should prompt
immediate evaluation by ENT (see Chapter 118 ENT Emergencies ). Patients
with hemorrhagic diathesis will require correction of their underlying disorder in
addition to procedural approaches described above to achieve hemostasis.
After treating any emergent problems, the evaluation should then proceed with

a thorough history. One should elicit frequency of nosebleeds, degree of difficulty
in achieving hemostasis, frequency of upper respiratory infections and/or allergic
discharge, symptoms of obstruction, and contributing factors such as recurrent
trauma from nose picking or other causes. Often asking children which finger
they pick their nose with will elicit a more honest answer. Other symptoms
sometimes reported are sequelae of swallowed blood such as hematemesis or
melena. Since the differential diagnosis for these conditions includes systemic
hemorrhagic disorders, one should elicit further history including family history
of bleeding. Menstrual history and any relation to epistaxis in adolescent girls is
worth noting.


Physical examination must include a complete general examination with
special attention paid to vital signs, including heart rate and blood pressure,
evidence of hematologic disease (enlarged lymph nodes, organomegaly,
petechiae, or pallor), and inspection of the nasal cavity after reasonable efforts to
stop any active bleeding. To facilitate the nasal examination, ask the child to blow
his nose or use suction to clear the nares. Using one’s thumb, the tip of the nose is
pushed upward to allow examination of the vestibule, the anterior portion of the
septum, and anterior portion of the inferior turbinate in search of the site of
bleeding, mucosal color, excoriations, discharge, foreign body or other mass, or
septal hematoma. A good light source, body fluid precautions, and in some cases,
a topical vasoconstrictor or decongestant can help. A more thorough examination
requires the use of a nasal speculum, which when passed vertically into the nares
and opened, allows examination of the septum, turbinates, and middle meatus.
Involvement of a child life specialist, anxiolytic medications, or restraints may be
necessary for such an examination in young children.
No laboratory workup is indicated in children without clinical evidence of
severe blood loss, in whom systemic factors are not suspected, and for whom an
anterior site of bleeding is identified and stopped readily with local pressure.

Reassurance and education about appropriate at-home management needs to be
provided. Home therapies may include use of a cool mist vaporizer to lessen
rhinitis sicca. An emollient, such as petroleum jelly or a topical antibiotic
ointment, placed in the nostrils twice daily is useful for maintaining normal
moistness of the nasal mucosa, and saline nasal spray may also be of some
benefit. Instructing parents to keep the child’s fingernails short is also helpful.
Occasionally, recurrent epistaxis during an acute upper respiratory infection or
flare-up of allergic rhinitis may be lessened with use of an antihistamine–
decongestant preparation, although care must be taken not to dry the nose
excessively. Potential side effects of these combination products argue against
their use in children younger than 6 years.
Evaluation for hemorrhagic diathesis should be performed in any child with
pertinent positive findings on history, family history, or physical examination.
This usually would include prothrombin time, partial thromboplastin time,
complete blood cell count, and a screening study for von Willebrand disease.
Importantly, mild bleeding abnormalities may, or may not, be detected by these
screening studies, so referral to a pediatric hematologist should be considered on
a case-by-case basis. Certain medications, such as valproate, have been associated
with epistaxis. These considerations are outlined in the epistaxis algorithm ( Fig.
26.1 ).


Epistaxis

i
Rapid screen for severe blood
loss, altered vital signs

Unstable

Stable

i

When stable

Complete history,
physical examination

Yes

Nasal findings?

lNo
Elevated blood pressure?

i
i

i
Yes

i
1. Stabilize patient.
2. ENT Consult.
3. Initiate hematologic workup.

Tumor
Telangiectasia
Polyps

Furuncle
Foreign body
Bacterial rhinitis/sinusitis
Rhinitis sicca
Local trauma/irritation

No

t
Flypertension

Suspicion of occult nasal lesion or hemorrhagic diathesis,
and/or severe epistaxis, frequent recurrence by history ?

i

i

Yes

No

i

1. ENT Consult
2. CBC, PT, PTT von Willebrand screen

Laboratory evidence of
hematologic disorder ?

jNo

Yes

i
Minor trauma and/or local
inflammation

Hemophilias, leukemia,
aplastic anemia, ITP,
or other bleeding disorder

Nasal lesion
Mild hemorrhagic disease
(von Willebrand disease,
primary platelet disorders),
or other systemic disease

FIGURE 26.1 Approach to diagnosis of epistaxis. ENT, ear, nose, and throat specialists; ORL,
otorhinolaryngology; CBC, complete blood count; PT, prothrombin time; PTT, partial
thromboplastin time; ITP, idiopathic thrombocytopenic purpura.

All patients discharged from the emergency department (ED) after evaluation
for significant epistaxis should be given specific instructions on nares