Epistaxis in children — formative SAQs

SAQ 1 — The seven-year-old with recurrent nosebleeds and bruising (10 marks, 15 minutes)

A seven-year-old girl is referred by her general practitioner for recurrent nosebleeds over four months, two to three times a week, each lasting up to ten minutes and usually from the left nostril. Her mother mentions she bruises easily and has "always had heavy periods," and an uncle had bleeding after a dental extraction. On examination there are a few small bruises on the shins and a faint petechial rash over the knees; the nose shows a prominent vessel on the anteroinferior septum. [2]

a) What is the most likely underlying diagnosis to consider, and which two historical features support it? (2 marks) [2]

b) State the first-line laboratory panel you would send, and the specific additional tests if the panel is abnormal, naming the commonest inherited cause. (3 marks) [2]

c) Explain why you would defer silver-nitrate cautery until after investigation, and state the one-side-of-the-septum rule and the complication it prevents. (3 marks) [6] [5]

d) Give the definitive management of the recurrent anterior bleeds, including one evidence-based topical measure and its duration, and the safety-net advice. (2 marks) [11]

SAQ 2 — The four-year-old with an active profuse nosebleed (10 marks, 15 minutes)

A four-year-old boy is brought to the emergency department with brisk bleeding from the nose for twenty minutes. His father has him tilted backward on a chair with a towel pressed against the bony bridge of the nose; the child has just vomited a small amount of swallowed blood. He is pale but alert, with heart rate 110 and capillary refill two seconds. [4]

a) State the two errors in the father's first-aid technique and the correct technique, including position and duration of pressure. (3 marks) [8]

b) Outline your immediate resuscitation and assessment, including intravenous access and the bloods you would send. (3 marks) [4]

c) The bleeding continues after correct first aid and topical vasoconstriction, with a visible anterior vessel. Describe the next two definitive steps, including the cautery rule and when you would pack. (3 marks) [6] [5]

d) Name two red flags in a child with epistaxis that would prompt imaging rather than simple cautery, and one diagnosis you must not biopsy in clinic. (1 mark) [12]