2.  History and Physical Exam Findings  Differential Diagnosis  Work up  Management

3.  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)

5.  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

6.  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

7.  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

8.  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

9.  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

10.  Red macular and papular telangiectasias of the lips and tongue

13. DisordersBleeding Time PltsPTPTTThrombi n Time Fibrinogen Vasculopathies, CTD LongNl Nl or ↑ Thrombocyto- penia Long↓Nl Qualitative platelet abnormalities LongNl or ↓Nl Hemophilia A (factor VIII deficiency) Nl LongNl Von Willebrand disease LongNl LongNl Disseminated Intravascular Coagulation Long↓ ↓ Adapted from UpToDate

14. Compression

15. Vasoconstriction Cautery  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

16. Matrix sealant Nasal packing  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

18.  Balloon catheter insertion  Embolization of the internal maxillary artery  Surgery (transnasal endoscopy and direct cautery or arterial ligation)

19.  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

20.  Messner, AH, et al. Evaluation of Epistaxis in Children. UpToDate. 2010  Messner, AH, et al. Management of Epistaxis in Children. UpToDate. 2010  www.Images.Google.com www.Images.Google.com