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History and Physical Exam Findings Differential Diagnosis Work up Management
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Nosebleeds account for <1% of ED visits Children <10 years usually have mild
nosebleeds that originate anteriorly Incidence: 4 in 1,000 in children under
10y Increased incidence in cold weather (low
humidity) and with increased air pollutants
Children <2 years rarely get nosebleeds so suspect trauma or serious illness (1/10,000)
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Age When did the
bleeding start? Unilateral or bilateral? How much blood loss? Blood in the mouth or
vomitus? What was done to
stop the bleeding? Trauma? Foreign body? Easy bruising or
bleeding?
PMHx? Nasal congestion,
discharge or obstruction?
Recent surgery? Family history? Medications? Associated
symptoms?› Headache or facial pain› Fever› Organomegaly› Hearing loss› Neck pain› Ecchymosis
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Vital Signs! (especially BP and HR) Pallor Petechiae, bruising or gingival bleeding Hemotympanum Oropharynx exam Mucosal telangiectasias or hemangiomas Enlarged lymph nodes or organomegaly Icterus Visual acuity and extraocular movements with
history of facial trauma Pale or bluish nasal mucosa or boggy turbinates
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CBC with smear Blood type and screen/cross-match PT PTT INR (for patients on anticoagulants) Von Willebrand factor if warranted CT or MRI if mass is suspected
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Trauma› Nose picking!› Foreign body› Child abuse› NG tube› Nasotracheal intubation
Mucosal Irritation› Dry air› Allergic Rhinitis› Inhaled irritants/drugs› URI› Localized skin or soft
tissue infection
Anatomic› Septal deviation› Unilateral choanal
atresia with asymmetric airflow
Other› Increased venous
pressure from coughing
Medications› Aspirin› Ibuprofen› Anticoagulants› Valproic Acid
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Tumors› Hemangioma› Juvenile NP
angiofibroma› Pyogenic granuloma› Rhabdomyosarcoma› NP carcinoma› Inverting papilloma
Granulomatous Disorders› Wegener’s› Sarcoidosis› Tuberculosis
Bleeding Disorders› Platelet disorders› Von Willebrand disease› Hemophilia› Inherited or acquired
coagulation disorders› Blood vessel disorders
(hereditary hemorrhagic telangiectasia aka Osler Weber Rendu syndrome)
Hypertension
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Red macular and papular telangiectasias of the lips and tongue
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Disorders Bleeding Time
Plts PT PTT Thrombin Time
Fibrinogen
Vasculopathies, CTD
Long Nl Nl Nl Nl Nl or ↑
Thrombocyto-penia
Long ↓ Nl Nl Nl Nl
Qualitative platelet abnormalities
Long Nl or ↓
Nl Nl Nl Nl
Hemophilia A (factor VIII deficiency)
Nl Nl Nl Long Nl Nl
Von Willebrand disease
Long Nl Nl Long Nl Nl
Disseminated Intravascular Coagulation
Long ↓ Long Long Long ↓
Adapted from UpToDate
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Compression
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0.05% oxymetazoline HCl (Afrin) or 0.25, 0.5 or 1% phenylephrine (20mcg/kg in children up to 25kg)
Side effects: headache, dizziness, dry nasal passage, nasal discharge, arrhythmia
Useful in patient with recurrent benign epistaxis
Chemical cautery with silver nitrate sticks Electrical cautery works well on a dry
surface Side effects: rhinorrhea and crusting;
ulceration and perforation
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Composed of collagen-derived particles and topical bovine-derived thrombin
Commercially available as Floseal In a small prospective, randomized controlled trial
patients in the Floseal group were found to have better control of their epistaxis than patients in the anterior nasal packing group
Fibrin glue is another option that has fallen out of favor since matrix sealants are available
Apply topical anesthesia and nasal decongestant first if possible
Small risk of toxic shock syndrome associated with packing
Neither prophylactic antibiotics nor impregnation of nasal packing with antibiotic ointment eradicate nasal carriage or are proven to prevent toxic shock syndrome
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Balloon catheter insertion
Embolization of the internal maxillary artery
Surgery (transnasal endoscopy and direct cautery or arterial ligation)
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Initial evaluation should focus on respiratory and hemodynamic stability of the patient
History and physical should focus on the source of the bleeding
Lab evaluation is indicated for patient with frequent recurrent nosebleeds, severe nosebleeds that are difficult to control and patients with a personal or family history of bleeding disorders
CT or MRI is indicated if a mass is suspected Compression is the first plan of action to stop the bleeding Other techniques can be administered with the
involvement of ENT to stop the bleed
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Messner, AH, et al. Evaluation of Epistaxis in Children. UpToDate. 2010
Messner, AH, et al. Management of Epistaxis in Children. UpToDate. 2010
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