Epistaxis in children — structured clinical encounter

Candidate brief

You are the paediatric registrar in the emergency department. A four-year-old boy is brought in with brisk bleeding from the nose for twenty minutes. His father has him tilted backward in a chair pressing a towel against the bony bridge of the nose, and the child has just vomited a small amount of swallowed blood. He is pale but alert, heart rate 110, capillary refill two seconds, with no history of bleeding disorder. [4]

Task

Take the focused history while applying correct first aid, present the corrected first-aid technique, justify your resuscitation and the stepwise escalation, and outline the cautery and packing decisions with the one-side-of-the-septum rule. Be prepared to teach the family the technique and the safety-net. A second child — a seven-year-old with recurrent epistaxis, bruising and a family history of bleeding — will then be introduced for contrast. [8]

Discussion anchors

• First-aid errors and correction: the father is tilting the child back and pinching the bony bridge — the correct technique is upright, leaning forward, firm continuous pressure on the soft lower part of the nose for at least 10 to 15 minutes, breathing through the mouth and spitting out blood. [8]
• Resuscitation and escalation: airway, breathing and circulation with intravenous access, full blood count, coagulation screen and group and save; keep the child upright and forward to protect the airway; escalate to topical oxymetazoline, silver-nitrate cautery of the visible point on one septal surface, then packing. [4] [6]
• Cautery rule and packing: cauterise one surface of the septum only to avoid septal perforation; pack with an absorbable or non-absorbable tampon if cautery fails or no point is visible; ENT referral for the posterior or refractory bleed. [5] [6]
• Contrast case: the seven-year-old with recurrent epistaxis, bruising and a family history of bleeding is a suspected bleeding disorder — von Willebrand disease is the commonest inherited cause; investigate with a full blood count, coagulation screen and iron studies, then von Willebrand factor antigen, ristocetin cofactor and factor VIII, and defer cautery until after work-up. [2] [11]
• Red-flag probe: an adolescent boy with unilateral progressive epistaxis and obstruction is juvenile nasopharyngeal angiofibroma — contrast CT and MRI, never biopsy in clinic, and ENT referral for embolisation and resection. [12]