Epistaxis

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS clinical disclaimer

Aim

To guide Emergency Department (ED) staff with the assessment and management of epistaxis.

Background¹

• Epistaxis in children is usually a minor self-limiting condition which responds to simple first aid measures.
• Rarely, a child with an underlying coagulation disorder may present with serious or even life threatening epistaxis.
• Children who present with a significant epistaxis that requires nasal packing should be discussed with an ear, nose and throat (ENT) specialist.

Anatomy²

• The nasal cavity has a rich vascular supply from several terminal branches of the internal and external carotid arteries.
• The mucosal surfaces of the anterior septum (Little’s area or Kiesselbach’s plexus) has a high concentration of vascular anastomoses.
• 95% of epistaxis in children occurs from Little’s area.

Aetiology² 

Often, no cause is apparent. 

The most common causes of epistaxis in children include:

Local

• Trauma – (e.g. nose picking, nasal fracture, forceful nose blowing, foreign body).
• Inflammation (e.g. upper respiratory tract infection, allergic rhinitis).
• Dry nasal mucosa (hot, dry climates).
• Hereditary Haemorrhagic Telangiectasia (HHT) is a rare autosomal dominant condition which often presents with epistaxis prior to 12 years of age.²

Systemic  

• Coagulation disorder (e.g. haemophilia, von Willebrand disease, thrombocytopenia).

Assessment

Investigations 

• Most cases need no investigation.
• Patients in whom epistaxis is recurrent, difficult to control or who have other features of coagulopathy (e.g. easy bruising) may warrant investigation for an underlying coagulation disorder.
  • Full blood count (FBC) and coagulation profile should be done to identify or exclude conditions such as haemophilia, von Willebrand’s disease or thrombocytopaenia.
• Epistaxis is rare before 2 years of age. Cases in younger children should raise suspicion of underlying coagulopathy or Non-Accidental Injury as an inciting factor.³
• The other demographic of interest are teenage males, where recurrent or profuse epistaxis (particularly posterior epistaxis) can be associated with Juvenile Nasal Angiofibroma (JNA). JNA is a benign fibrovascular neoplasm that typically arises in the region of the sphenopalatine foramen in the lateral wall of the nose.³

Management¹

Resuscitation

Rarely a child will present with life threatening haemorrhage. If haemodynamically unstable or shocked general principles of resuscitation apply (refer to Serious illness).

• Position the patient upright if possible (i.e. not shocked) and apply pressure to nasal ala.
• If unconscious, lie on their side.
• Instruct the patient to breathe through the mouth, and clear the upper airway by suctioning blood from the oropharynx using a Yankauer sucker.
• Prompt venous access and volume resuscitation with crystalloid or blood.
• Prompt nasal packing with a haemostatic dressing or device.
• Urgent ENT consultation.
• After adequate resuscitation, formal haemostatic control in the operating theatre may be necessary if bleeding persists.

First aid

• Sit up and lean forward (do not tilt the head back – results in concealed, swallowed blood).
• Pinch nasal ala (soft anterior part of the nose) to exert pressure on the Little's area.
  • Pressure should be applied for a full 15 minutes, by the clock.
  • Ice to suck on or cold pack on the back of the neck can help slow blood flow to the nose.
  • Do not stop pressure intermittently to check for bleeding.
• Application of a vasoconstrictor lidocaine 5% with phenylephrine nasal spray (Co-Phenylcaine™ Forte) or dilute adrenaline (epinephrine) may be used as an adjunct to pressure. If using lidocaine (lignocaine) with phenylephrine nasal spray, be aware of the cumulative dose of lidocaine as the potential for toxicity exists, especially via traumatised mucosal surfaces⁴.
• This technique will control the majority of epistaxis in the ED.
• If simple nose pressure of reasonable duration does not achieve haemostasis, then anterior nasal packing or cautery may be needed.

Anterior nasal packing

The most basic emergency procedure that can be performed with good control of epistaxis is anterior nasal packing. This is generally poorly tolerated in children and most children will require both topical anaesthetic spray and carefully titrated intravenous opiate such as morphine to allow packing. Refer to Morphine Monograph – Medication Management Manual (Internal WA Health only).

Technique

• Material: packing forceps, nasal packing material (e.g. Nasopore® or Merocel®) or balloon tamponade device (e.g. Rapid-Rhino), topical vasoconstrictor / anaesthetic spray (e.g. lidocaine with phenylephrine nasal spray (Co-Phenylcaine™ Forte)).
• Position patient sitting upright.
• Spray a topical vasoconstrictor / anaesthetic into each nostril.
• Titrate IV Morphine to provide anxiolysis and decrease the distress of the packing procedure. Refer to Morphine Monograph – Medication Management Manual (Internal WA Health only). 

Balloon devices

• A range of commercial devices exist to control either posterior bleeds, anterior bleeds or both.
• Alternatively, a size 8 French Foley catheter, inserted deep into the nasopharynx, inflated with air and then pulled anteriorly to sit in the posterior choana can control posterior bleeds.
• Rapid Rhino (epistaxis device) if available is preferable. They are available in different lengths between 5.5cm and 9cm and are covered in a fabric mesh that exudes a pro-coagulant, lubricating gel when soaked in water (not saline) before use.
  • Remove blue plastic covering first, after insertion gently inflate pilot balloon with air (less than 5 mL is usually needed in children). Anti-staphylococcal oral antibiotics should be commenced if non-dissolvable packing (i.e. RapidRhino® or Merocel®).
• Additional methods may be employed if anterior bleeds are coexistent.

Nasal packing

With patient sitting up:

• Choose appropriate size, larger tampons may be trimmed to size.
• Coat the leading end of tampon with a lubricating ointment.
• Grasp with forceps and insert along nasal floor.
• Tape strings to cheeks.
• A small amount of saline may be applied to tampon, to soften and expand it.
• Discuss patient disposition with ENT.

Nasal cauterisation – only by experienced doctors

• Haemostasis and patient co-operation is required before cauterisation.
• Silver Nitrate sticks are used for chemical cautery.
• Mostly used to control bleeding vessels on the anterior part of the nasal septum (Little’s area).
• Additional equipment: torch or head light, nasal speculum, suction.
• Apply lidocaine with phenylephrine nasal spray (Co-Phenylcaine™ Forte) to the area to vasoconstrict as well as anaesthetise the area. This can be sprayed on the area, but a better anaesthetic effect is produced if a similar volume of lidocaine (lignocaine) with phenylephrine nasal spray (Co-Phenylcaine™ Forte) is applied to the area for a longer period of time (20 minutes) via a small cotton-wool pledget.
• Apply the silver nitrate stick to the edge of the bleeding area. Aim to cauterise the feeding vessels first before moving to the central bleeding focus.
• Apply the stick for a maximum 10 seconds at a time. Generally, application for 3 seconds in one area is sufficient. If you want to move the silver nitrate applicator to an adjacent area, aim to roll the applicator rather than dragging it.
• Cauterise a minimal part of the septum, to avoid ulceration.
• Never cauterise both sides of the septum at the same time.

Discharge advice

• Avoid nose picking or rubbing.
• Avoid nose blowing, picking, strenuous exercise/sports for 2 weeks.
• Use a saline nasal spray and emollient for 2 weeks at least.
• Continued emollient ointment regularly (BD) to the area for at least one week. Continued emollient use may be beneficial, with emollients alone controlling 65-77%³ of recurrent paediatric epistaxis.
• First aid advice (as above) for future episodes.
• Referral to ENT clinic if epistaxis is a recurrent problem.

References

1. Textbook of Paediatric Emergency Medicine 3rd Edition Cameron P, Browne GJ, Mitra B, et al (2018) Publisher: Elsevier Edition updated
2. Messner AH (2014) Management of Epistaxis in Children. UpToDate. Accessed at www.uptodate.com
3. Patel N, Maddalozzo J, Billings KR. An update on management of pediatric epistaxis. Int J Pediatr Otorhinolaryngol. 2014 Aug;78(8):1400-4. doi: 10.1016/j.ijporl.2014.06.009. Epub 2014 Jun 16. PMID: 24972938.
4. Co-Phenylcaine Forte. MIMS Online 2024. [Last Updated: 1 October 2018, Cited: 9 October 2024] Available from: MIMS | MIMS | Full Product Information (health.wa.gov.au)

Endorsed by:	Nurse, Co-director, Surgical Services	Date:	Oct 2024
		Next review date:	Oct 2027

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