Acute Epistaxis: A Comprehensive Overview in the Acute Care Setting

Table of Contents

 

About This Issue

Epistaxis is a common condition in pediatric patients. Patients may seek treatment in the emergency department if bleeding is severe, refractory, or recurrent. While most cases of epistaxis are benign in nature, there are some unusual conditions that present with epistaxis that can be serious and require prompt investigation and treatment. This issue discusses the various etiologies of epistaxis and provides evidence-based recommendations for the evaluation and management of pediatric epistaxis. In this issue, you will learn:

Common causes of epistaxis, including local causes, systemic causes, and causes of recurrent epistaxis

Conditions included in the differential diagnosis of epistaxis

Key questions to obtain while taking the history

Physical examination findings that will help differentiate local epistaxis from systemic epistaxis

When laboratory studies or imaging studies are indicated

Recommendations for general and scenario-specific management of pediatric epistaxis, including which medications to use and when to progress to cautery, nasal packing, nasal balloon catheter, and surgical intervention

Which patients can be discharged home, and which should be admitted

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Etiology
   2. Pathophysiology
7. Differential Diagnosis
   1. Local Causes
   2. Systemic Causes
   3. Recurrent Epistaxis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
11. Treatment
    1. Visualization
    2. Topical Medications
    3. Cautery
    4. Nasal Packing
    5. Nasal Balloon Catheter
    6. Surgical Intervention
    7. Persistent and Prolonged Bleeding
    8. Long-Term Management
12. Special Populations
13. Controversies and Cutting Edge
14. Disposition
15. 5 Things That Will Change Your Practice
16. Risk Management Pitfalls for Children with Epistaxis
17. Summary
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathway for Management of Epistaxis in Pediatric Patients
21. Tables and Figures
22. References

Abstract

Epistaxis is a common problem in pediatric patients. Most cases are benign in nature and resolve with minimal intervention. However, there are many unusual conditions that present with epistaxis that can be very serious and should be promptly investigated and treated. This review aids in the distinction between the benign causes of epistaxis and those that are more serious and require further evaluation. The various etiologies of epistaxis are discussed, and recommendations for general and scenario-specific management of pediatric patients with epistaxis are provided.

Case Presentations

A mother brings her 2-year-old boy to the ED for profuse nose bleeding...

• The boy has no history of bleeding disorders or reported trauma. According to the mother, the nosebleed “came out of nowhere.”
• On examination, you note some bilateral periorbital bruising. The child is otherwise active and healthy.
• What are your first steps, and what are you thinking about as you formulate a differential diagnosis?

A 3-year-old boy who repeatedly presents with nosebleeds returns to the ED...

• On this occasion, he looks very pale. According to his mother, he has been bleeding off and on for the last 24 hours. He is not currently bleeding.
• What are the main concerns on your differential diagnosis and how should you evaluate this patient?

A 15-year-old boy with a large amount of bleeding from his nose is brought into the ED via EMS…

• The boy has been applying pressure as directed by EMS, but the bleeding has continued. Additionally, he states that this has been going on for the past year, and generally he is able to control it.
• What concerning diagnosis must be considered and how should you assess for this diagnosis? Since pressure has been ineffective, what should you do to stop his bleeding?

A 4-year-old girl is brought to the ED with frequent episodes of nosebleeds over the past 6 months...

• The mother states that she is concerned about how often it is happening. The girl is otherwise healthy and has never had any other issues with prolonged bleeding. According to the mother, the girl has seasonal allergies.
• What diagnosis is most likely? What should you recommend to manage this issue?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Pallin DJ, Chng YM, McKay MP, et al. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med. 2005;46(1):77-81. (Chart review; 4,503,000 visits) DOI: 10.1016/j.annemergmed.2004.12.014

4. * Passali D, Damiani V, Passali FM, et al. An international survey on the pragmatic management of epistaxis. Acta Biomed. 2020;91(1-S):5-10. (Survey; 43 countries) DOI: 10.23750/abm.v91i1-S.9241

11. * Bequignon E, Teissier N, Gauthier A, et al. Emergency department care of childhood epistaxis. Emerg Med J. 2017;34(8):543-548. (Review) DOI: 10.1136/emermed-2015-205528

12. * Patel N, Maddalozzo J, Billings KR. An update on management of pediatric epistaxis. Int J Pediatr Otorhinolaryngol. 2014;78(8):1400-1404. (Retrospective study; 175 patients) DOI: 10.1016/j.ijporl.2014.06.009

14. * Send T, Bertlich M, Eichhorn KW, et al. Etiology, management, and outcome of pediatric epistaxis. Pediatr Emerg Care. 2021;37(9):466-470. (Retrospective study; 58 patients) DOI: 10.1097/PEC.0000000000001698

17. * Makhasana JA, Kulkarni MA, Vaze S, et al. Juvenile nasopharyngeal angiofibroma. J Oral Maxillofac Pathol. 2016;20(2):330. (Case report) DOI: 10.4103/0973-029X.185908

21. * Jamil W, Rowlands G. A practical approach to recurrent epistaxis in children. Paediatr Child Health. 2019;29(6):279-280. (Review) DOI: 10.1016/j.paed.2019.03.005

24. * Joseph J, Martinez-Devesa P, Bellorini J, et al. Tranexamic acid for patients with nasal haemorrhage (epistaxis). Cochrane Database Syst Rev. 2018;12(12):CD004328. (Meta-analysis; 692 participants) DOI: 10.1002/14651858.CD004328.pub3

28. * Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. 2005;81(955):309-314. (Review) DOI: 10.1136/pgmj.2004.025007

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Keywords: epistaxis, pediatric epistaxis, anterior epistaxis, posterior epistaxis, recurrent epistaxis, nosebleed, pediatric nosebleed, acute nosebleed, nose picking, juvenile nasopharyngeal angiofibroma, hereditary hemorrhagic telangiectasia, von Willebrand disease, granulomatosis with polyangiitis, Wegener granulomatosis, sarcoidosis, cautery, nasal packing, nasal balloon catheter, septal bleed