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 ENT specialist
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
Often, no cause is apparent. The most common causes of epistaxis in children include:
Trauma – e.g. nose picking, nasal fracture, forceful nose blowing, foreign body
Inflammation (e.g. URTI, allergic rhinitis)
Dry nasal mucosa (hot, dry climates)
Coagulation disorder (e.g. haemophilia, von Willebrand’s disease, thrombocytopenia)
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.
FBC and Coagulation profile should be done to identify or exclude conditions such as haemophilia, von Willebrand’s disease or thrombocytopaenia
Rarely a child will present with life threatening haemorrhage. If haemodynamically unstable or shocked general principles of resuscitation apply (see Serious Illness)
Position the patient upright if possible (i.e. not shocked) and apply pressure to nasal ala
If unconscious, lie on their side in Trendelenburg position
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 nasal balloon or nasal tampon
Urgent ENT consultation
After adequate resuscitation, formal haemostatic control in the operating theatre may be necessary if bleeding persists
Sit up and lean forward
Pinch nasal ala (soft anterior part of the nose) to exert pressure on the Little’s area.
Pressure should be applied for a full 10 minutes
Application of a vasoconstrictor such as Co-phenylcaine may be used as an adjunct to pressure
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.