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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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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
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Compression
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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
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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
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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 www.Images.Google.com www.Images.Google.com
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