9-year old with acute onset epistaxis and low platelet count
Patient will present as → a 14-year-old who is brought to your Emergency Department (ED) with an intractable nosebleed. Pinching of the nose has failed to stop the bleed. In the ED a topical vasoconstrictor is tried but also fails to stop the bleeding.
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Kiesselbach's Plexus or Little's Area is the most common site for anterior bleeds
- Woodruff's Plexus is the most common site for posterior nosebleeds
- The sphenopalatine artery is generally the source of severe posterior nosebleeds causing bleeding from both nares and posterior pharynx
- Patients should always be asked about aspirin or ibuprofen use
The majority of patients do not require testing other than direct visualization
- Patients with symptoms or signs of a bleeding disorder and those with severe or recurrent epistaxis should have CBC, PT, and PTT.
- CT may be done if a foreign body, a tumor, or sinusitis is suspected.
Most nosebleeds are anterior and stop with direct pressure
- Apply direct pressure at least 10-15 minutes, seated leaning forward
- Short-acting topical decongestants (two sprays of oxymetazoline (Afrin), phenylephrine, cocaine)
- Anterior nasal packing
- Patients with nasal packing must be treated with antibiotics (cephalosporin) to prevent toxic shock syndrome and the patient has to return to take the packing out
- If there is no packing in the nose, place a small amount of petroleum jelly or antibiotic ointment inside the nostril 2 times a day for 4–5 days
- Posterior balloon packing is used to treat posterior epistaxis. These patients must be admitted to the hospital and prompt consultation with an otolaryngologist is indicated
- Recurrent epistaxis: Must rule out hypertension of hypercoagulable disorder
Question 1 |
replace with Gelfoam packing Hint: Gelfoam packing, cauterization of Kiesselbach's plexus, and topical lidocaine and epinephrine are helpful in treating an anterior bleed, but not in a posterior bleed. | |
cauterize Kiesselbach's plexus Hint: See A for explanation. | |
insert a posterior balloon pack | |
apply topical solution of lidocaine and epinephrine Hint: See A for explanation. |
Question 2 |
electrocautery of the bleeding site. Hint: Cautery is not used because the edges of the cauterized area may begin to bleed. | |
silver nitrate application Hint: Silver nitrate is not used in children because it increases the risk for nasal septal perforation. | |
posterior nasal packing Hint: Posterior nasal packing is indicated for posterior bleeds in the inferior meatus. | |
intranasal petrolatum gauze |
Question 3 |
Middle turbinate Hint: See D for explanation. | |
Posterior ethmoid artery Hint: See D for explanation. | |
Kiesselbach's triangle | |
Inferior turbinate Hint: The inferior turbinate is the most common location for posterior epistaxis. |
Question 4 |
Electrical cautery Hint: Cautery and direct pressure are effective in anterior, not posterior epistaxis. | |
Direct pressure on the nose Hint: See A for explanation. | |
Petroleum jelly application Hint: Petroleum jelly application is not indicated in posterior epistaxis. | |
Posterior nasal packing |
List |
References: Merck Manual · UpToDate