Acute onset, epistaxis

Standard Approach
Suggested Approach

• Most pediatric epistaxis is a benign condition.
• Start by assessing the patient’s airway control; usually, they are able to protect their own airway. Position them leaning forward and encourage them to spit out any blood. Swallowing blood leads to vomiting and may compromise the airway.
• No need to give oxygen by nasal cannula, the nose is full of blood! However, if the patient is short of breath, altered mental status, or showing signs of shock, give oxygen by mask, but keep an eye on the airway and allow them to spit-up any blood.
• Monitor vital signs closely – specifically, the heart rate and skin signs as they are most sensitive. In this case the heart rate was reassuring and the patient had no signs of shock.
• This presentation is usually caused by trauma from the child picking their nose or dry air. In this case, the child denied any trauma. It’s important to ask specifically about digital trauma or “picking your nose,” though many people do this without thinking about it and may not remember.
• In this case, the patient was hemodynamically stable and without signs of shock, otherwise starting an IV and giving a fluid bolus would be indicated.
• The first step, as with most bleeding, is to apply direct pressure. The most common mistake parents make when applying pressure is they don’t do this long enough. The general approach should be to have the child put their face forward and pinch the nose for 5-10 minutes – without letting go – to see if the bleeding has stopped. This will tamponade the very friable plexus of blood vessels in the nose.
• In this case, the parents were unable to achieve hemostasis. If direct pressure doesn’t work, no further prehospital efforts at controlling the bleeding are required. Do not attempt to pack the nose in the prehospital setting. Position the patient for drainage, provide suction, maintain a clear and patent airway, treat for shock and transport.
• Lights and sirens for transport would be indicated if the patient was in severe shock, unconscious, had an uncontrolled airway or massive hemorrhage from the nose and/or mouth. This is rare, but in these cases the basics still apply. Position the patient for drainage, protect the airway (intubate if necessary – keeping in mind that intubation may be difficult with severe bleeding, and BLS techniques are often very effective for clearing the airway and allowing for adequate oxygenation and ventilation), and treat for shock.
• After failing basic measures, one needs to think of other etiologies. Many parents will become concerned with blood disorders such as hemophilia or leukemia, and, although these are on the differential, most children with these serious conditions have additional symptoms, including bruising, fatigue, bloody gums with brushing of teeth, etc.
• ITP (idiopathic thrombocytopenic purpura) is an autoimmune condition that results in low platelets and often may need transfusions, steroids or even splenectomy in rare cases. The condition is usually self-limited and resolves in 2-3 months.
• The prehospital approach should focus on the ABCs, as always, with attention to the circulatory system, as a child can lose a significant amount of blood quickly.
• Direct pressure is all that is needed generally, but IV hydration may be necessary if bleeding has been ongoing for a long period of time, or if any worrisome vital sign changes occur, with tachycardia being the first sign and hypotension a very late sign.

Notes

• This case is an excellent reminder to have a low threshold to transport when the history does not match the complaint. Because the medics took note that there was no history of digital trauma and the bleeding was from both nares, they picked up on the fact that this was a spontaneous bleeding disorder. Allowing this patient to decline transport would likely have resulted in being called back to the scene later only to find the patient with the potential for airway compromise and hemorrhagic shock.

Suggested references

• When It Rains, It Pours: Blood Thinners Complicate a Nosebleed
• An Update on Management of Pediatric Epitaxis