Emergency Department care of childhood epistaxis

Pediatric Epistaxis-Effectiveness of Conservative Management

OBJECTIVES

Epistaxis is an emergency medical condition that sometimes requires admission to the emergency department. Pediatric epistaxis differs from epistaxis in the older population in terms of etiology, severity, and management. Our objective was to identify the distinctive features of pediatric epistaxis and determine the appropriate management.

METHODS

This was a retrospective study of 231 medical records of children (<18 years old) with epistaxis of a total of 1171 cases in the general population who presented to our medical center's emergency department between 2013 and 2018.

RESULTS

Among 231 admissions, 10 children (4.3%) presented more than once. Male patients accounted for the majority of cases (64.5%), and the average age was 9.4 years. Two children were treated with aspirin because of cardiac valve disease. Anterior bleeding was detected in 101 cases (43.7%), whereas posterior origin was observed in 8 cases (3.5%). In 122 cases (52.8%), there was no active bleeding observed. Nose injury was the cause of epistaxis in 24 cases (10.4%), and 16 admissions (6.9%) followed nasal surgical interventions. Nineteen children (8%) had abnormal coagulation tests, and 7 patients (3%) received blood transfusions. Chemical cauterization was performed in 89 cases (39.3%), and anterior packing was needed in only 9 cases (3.9%). Nine children required hospitalization (3.9%), and 2 needed surgical intervention to control bleeding. Compared with the adult population, there were significantly fewer cases of active bleeding, recurrent epistaxis, anterior packing, or need for hospitalization in the pediatric population.

CONCLUSIONS

Epistaxis is significantly less severe in the pediatric population, with only a few cases requiring major intervention. Endoscopic examination of the entire nasal cavity and routine coagulation tests are not mandatory unless there is a history of recurrent epistaxis, known coagulopathy, antiplatelet/anticoagulation therapy, or a suspicion of juvenile idiopathic angiofibroma. We suggest using absorbable packs, which offer advantages over cauterization or nonabsorbable packs.

Risk Factors and Management Outcomes in Pediatric Epistaxis at an Emergency Department

BACKGROUND

Most cases of pediatric epistaxis are spontaneous and self-resolve. However, a subset of children may experience significant bleeding and require procedural or medical intervention.

OBJECTIVE

We aim to identify risk factors associated with moderate and severe epistaxis in the emergency department (ED) and explore management outcomes.

METHODS

We retrospectively reviewed all patients under 22 years old with epistaxis who presented to our ED between 2013 and 2022. Epistaxis severity was defined as mild (required nasal compression or intranasal medications), moderate (required cautery or packing), or severe (required factor replacement, transfusion, hospital admission, or surgery). We performed univariable and multinomial regression analyses, with risk factors and outcomes analyzed according to severity.

RESULTS

Of 858 visits, 41 (5%) patients had moderate and 67 (8%) had severe epistaxis. Patients with moderate epistaxis were older than those with mild and severe epistaxis (median 15.6 vs. 8.3 vs. 10.7 years, p < 0.001). In regression analysis, moderate epistaxis was associated with older age, prior ED visit within 72 h, and antiplatelet medication use (p < 0.01). Severe epistaxis was associated with bleeding disorders, nasal procedures within 30 days, and anticoagulation medication use (p ≤ 0.001). Bleeding over 30 min prior to arrival was associated with both moderate and severe epistaxis (p < 0.05). Of the 67 patients with severe epistaxis, 10 (15%) required factor replacement, 28 (42%) required transfusion, 52 (77%) required hospital admission, and 5 (7%) underwent surgery.

CONCLUSION

Epistaxis severity is associated with certain risk factors. However, most cases of pediatric epistaxis are mild and do not require intervention or ED evaluation.

Age Distribution of Epistaxis in Outpatient Pediatric Patients

Objectives: Little is known about the prevalence of epistaxis in children. Existing reports focus on hospitalized children or those presenting to an emergency department. To better understand pediatric epistaxis in clinical practice, we sought out a searchable, representative outpatient database and examined the incidence of epistaxis in children of different ages. Methods: A cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from the years 2007 to 2011 was performed. The NHAMCS is a Centers for Disease Control and Prevention-curated national sample of data from visits to non-federally employed office-based physicians and health centers. We queried the NHAMCS to determine the cumulative incidence of epistaxis in children of different age groups. The International Classification of Diseases Ninth Revision code 784.7 was chosen to identify epistaxis. Comparisons of rates were performed using the chi-squared test. A P-value of <.05 was considered statistically significant. Results: In total, 55,435,691 children [27,816,237 (50.2%) males, 55,435,691 (77.2%) white] were included. The overall cumulative incidence rate of epistaxis was 2.4/1000 children. Children in the 3- to 5-year range had the highest cumulative incidence of epistaxis (5.0/1000), followed by those in the 6 to 8 (3.0/1000), 9 to 11 (2.0/1000), 0 to 2 (1.9/1000), 12 to 14 (1.6/1000), and 15 to 17 (0.5/1000) year ranges (P < .001). Conclusion: Pediatric epistaxis is common in the office setting (2.4 per 1000 children)-and well above emergency department estimates (1.7 per 1000 people). Children between the ages of 3 to 5 years have the highest cumulative incidence. Epistaxis is sufficiently unusual in infants and the late teens that alternative causes for nasal bleeding should be included in the differential diagnosis.

Epistaxis Treatment Options: Literature Review

Epistaxis means bleeding from nostrils, nasal cavity or nasopharynx. To summarize the available epistaxis treatment options. Methods: 61 articles published in the last 20 years were included. Duplicate records, irrelevant and inaccessible ones were excluded.  Epistaxis can be treated with first aid measures such as external pressure and ice packing and applying topical agents, e.g. oxymetazoline that stops 65-75% of nosebleeds in A&E. Also, with electrocautery which is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization and applying tranexamic acid that promotes hemostasis in 78% of patients, versus 35% and 31% respectively in patients treated with oxymetazoline and nasal packing. Furthermore, nasal packing can be applied with non-absorbable materials, e.g. petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino), absorbable materials, e.g. nasal tampon (Nasopore), and with newer hemostatic materials which are more effective and with fewer complications, e.g. hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) and fibrin glue. Moreover, epistaxis can be achieved with endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing (97% vs. 62%), and with endoscopic cauterization which is more effective than ligation. Finally, for intractable cases embolization can be applied using gelatin sponge, foam, PVA and coils with 80% success rate and comparable efficacy and complications to surgical methods. Epistaxis can be dealt with various methods depending on patient's history and available resources. Newer hemostatic agents in combination with endoscopic methods have advantages over traditional methods.

Analysis of Multimorbidity of Moderate to Severe Allergic Rhinitis in Children: A Real-World Study

INTRODUCTION

Allergic rhinitis (AR) in children is associated with various comorbidities, posing challenges for treatment and management. There have been few investigations of these multimorbidities in Chinese children with AR. Here, we investigated the prevalence of multimorbidities in children with moderate to severe AR and analyzed the influencing factors using real-world data.

METHODS

In total, 600 children who visited the outpatient clinic of our hospital and were diagnosed with moderate-severe AR were prospectively enrolled. All children underwent allergen detection and electronic nasopharyngoscopy. Parents or guardians completed a questionnaire that included age, sex, mode of delivery, feeding pattern, and familial history of allergy. The multimorbidities investigated included atopic dermatitis (AD), asthma, allergic conjunctivitis (AC), chronic rhinosinusitis (CRS), adenoid hypertrophy (AH), tonsil hypertrophy (TH), recurrent epistaxis, and recurrent respiratory tract infections (RRTIs).

RESULTS

The AR multimorbidities reported in children were as follows: recurrent epistaxis (46.5%), AC (46.3%), AD (40.7%), asthma (22.5%), RRIs (21.3%), CRS (20.5%), AH (19.7%), and TH (12.5%). In univariate logistic regression analysis, age (<6 years), birth mode, familial history of allergy, and single dust mite allergy were associated with AR multimorbidity (p < 0.05). Multivariate logistic regression revealed that a familial history of allergy was an independent risk factor for AC (odds ratio [OR] = 1.539, 95% confidence interval [CI]: 1.104-2.145) and AH (OR = 1.506, 95% CI: 1.000-2.267) (p < 0.05). Age (<6 years) was independently associated with the risk of AD (OR = 1.405, 95% CI: 1.003-1.969) and RRTIs (OR = 1.869, 95% CI: 1.250-2.793) (p < 0.05), cesarean section with AR and CRS risk (OR = 1.678, 95% CI: 1.100-2.561), and single dust mite allergy with asthma (OR = 1.590, 95% CI: 1.040-2.432) and CRS (OR = 1.600, 95% CI: 1.018-2.515) risk (p < 0.05). Further, non-dust mite allergy was independently associated with AR and CRS (OR = 2.056, 95% CI: 1.084-3.899).

CONCLUSION

AR was found to be accompanied by different comorbidities, including both allergic and non-allergic comorbidities, complicating disease treatment. These findings demonstrated that age (<6 years), familial history of allergy, types of allergens, and cesarean section were risk factors for different multimorbidities associated with AR.

Low-intensity diode laser combined with nasal glucocorticoids in the treatment of recurrent epistaxis in children: a randomized controlled trail

BACKGROUND

A painless and effective treatment of childhood epistaxis is needed.

OBJECTIVE

To observe the effectiveness of low-intensity diode (Lid) laser in treating epistaxis complicated with allergic rhinitis in children.

METHODS

Our study is a prospective, randomized, controlled, registry trial (NO. 202001201) involving 44 recurrent epistaxis children (<14 years old) with or without Allergic Rhinitis (AR) in our hospital. They were divided randomly into the Laser and Control groups. The Laser group was treated with Lid laser (wavelength 635 nm, power 15mW) for 10 min after nasal mucosa was moistened with normal saline (NS). The Control group moistened their nasal cavities with NS only. Children in two groups complicated with AR were given nasal glucocorticoids for 2 weeks. The effectiveness of Lid laser in treating epistaxis and AR were compared between the two groups after treatment.

RESULTS

After treatment, the effective rate of the Laser group in epistaxis (23/24, 95.8%) was higher than the Control group (16/20, 80%) (p < .05). The VAS scores of the children complicated with AR in the two groups both improved after treatment, however, the variation of VAS score (3.02 ± 1.50) in the Laser group was greater than the Control group (1.83 ± 1.56) (p < .05).

CONCLUSION

As a safe and efficient method, Lid laser treatment can effectively alleviate epistaxis and inhibit symptoms of AR in children.

[Epidemiology and modern methods of treatment of non-traumatic nosebleeds]

Data on the detection incidence of nosebleeds (NBs) of non-traumatic origin in the population show considerable variability in statistical indicators, and NBs treatment and consequences depend on the localization of hemorrhage source, the volume of blood loss, patient's general condition, the presence and nature of comorbid pathology and a number of other factors. There are some differences in the choice of NBs treatment options, evaluation of their clinical and economic efficiency, which indicates the need to analyze and systematize the results of such studies.

OBJECTIVE

To analyze data on prevalence and current treatment approaches of non-traumatic nosebleeds.

MATERIAL AND METHODS

The search for publications (articles and related abstracts) on the subject of the study, presented in the PubMed database, has been conducted. The choice of material was made according to the following key words: non-traumatic nosebleeds, causes, incidence, methods of stopping nosebleeds.

RESULTS

The literature data show a significant prevalence of NBs in the population, their potential hazard to the life of patient and the importance of clinical and demographic characteristics of persons for determining treatment tactics in each case. In practical terms, primary and secondary NBs should be distinguished. In case of primary NB, the use of coagulation and nasal packing is recommended after determining the place of bleeding. In secondary NB it is necessary to establish its cause in order to assess risk factors and apply appropriate topical or systemic drug therapy. The so-called difficult (difficult-to-treat) NBs deserve special attention. As a rule, these cases involve bleeding from the posterior parts of nose. The analysis of publications shows a high (90%) efficacy of surgical interventions, used as first-line treatment. Effectiveness of embolization in such cases was 75% and of anterior/posterior nasal packing was 62%.

CONCLUSION

The literature data show a significant prevalence of nosebleeds in the population and their potential hazard to the life of patient. The existing differences in the assessments of treatment options for this pathology, their clinical and economic efficiency are the basis for further research, in particular, to clarify the causes of nosebleeds' occurrence and recurrence, the impact of treatment methods on quality of patients' life.

Epistaxis duration predicts bleeding in immune thrombocytopenia: a cohort study

OBJECTIVE

To test for an association between duration of epistaxis and clinically relevant bleeding in the following 12 months in children with immune thrombocytopenia (ITP).

DESIGN

Prospective cohort study.

SETTING

The national UK Paediatric ITP registry, a multicentre prospective clinical registry of new cases of ITP between 2006 and February 2020.

PATIENTS

All children aged between 2 months and 16 years in participating UK centres.

EXPOSURE

Epistaxis at presentation defined as none, <10 min, 10-30 min and >30 min.

MAIN OUTCOME MEASURES

Incident severe bleeds, combined moderate and severe bleeds and drop in haemoglobin (Hb) by ≥20 g/L.

RESULTS

The sample included 1793 patients, of which 334 had epistaxis <10 min, 88 lasting 10-30 min and 97 >30 min. In the 12 months following presentation, 19 had a severe bleed, 140 had a moderate bleed and 54 had a drop in Hb ≥2 g/dL. Epistaxis >30 min duration was associated with increased odds of severe bleeds (OR 1.43-15.67), moderate or severe bleeding (OR 1.33-4.2) and drop in Hb (OR 1.23-6.91). Shorter duration epistaxis was not associated with increased odds of any outcome. A trend for increased odds with longer duration epistaxis was significant for all outcomes.

CONCLUSIONS

The longer the duration of epistaxis at presentation with ITP, the higher the risk of a clinically significant bleeding event in the 12 months following. This should inform clinical severity ratings and treatment decisions.

Efficacy of Topical Silver Nitrate for Control of Post-tonsillectomy Hemorrhage

Objective

Management of patients with post-tonsillectomy hemorrhage (PTH) is not well defined but may include observation, topical bedside treatments, or return to the operating room. Data on the use and efficacy of silver nitrate as a topical bedside agent for the management of PTH remain unexplored. Our primary objective was to assess the efficacy of silver nitrate in reducing the need for operative control of PTH.

Methods

Single-institution retrospective chart review included patients aged 5-18 years who presented with tonsillar bleeding within 30 days of tonsillectomy. Patients undergoing observation or bedside silver nitrate cautery were compared based on clinical characteristics and experience of the physician performing the procedure. The outcome of interest was rebleeding requiring operative control. Sample characteristics according to treatment modality were described using Fisher’s exact tests and ANOVA.

Results

Of the patients eligible for inclusion, 29 (20%) were observed and 70 (48.3%) were treated with topical silver nitrate. Age was the only statistically significant clinical difference among treatment groups. The silver nitrate group had more patients who underwent operative control of PTH compared to the observation group (p = 0.004). When comparing the need for operative control between the observation group and patients who had initial success with silver nitrate, there was no difference (p = 0.29). No differences were found in the rate of bleeding requiring operative control when comparing experience of the physician performing the procedure (p = 0.20).

Conclusion

More patients who underwent silver nitrate cautery required PTH control in the operating room compared to the observation group. This may be due to patient selection as our results also suggest that there is no statistical difference in rates of operative control of PTH when comparing initial successful treatment with topical silver nitrate to observation. Age is likely a factor that was used by physicians in this study to decide the initial management of PTH. Provider experience does not appear to affect rebleeding rates. Future studies are necessary to evaluate the clinical impact of silver nitrate in the context of PTH and will benefit from more robust sample sizes and enhanced diversity in the sample group.

Case report: A case of acquired von Willebrand syndrome as onset clinical presentation of systemic lupus erythematosus manifested as epistaxis and pulmonary hemorrhage

BACKGROUND

Acquired von Willebrand syndrome (AVWS) is a less common bleeding disorder, primarily manifested as mild to moderate mucocutaneous bleeding and laboratory tests are similar to hereditary von Willebrand disease (VWD). AVWS is secondary to other diseases, and systemic lupus erythematosus (SLE) is a relatively rare cause.

CASE PRESENTATION

We report a case of AVWS as onset clinical presentation of SLE manifested as epistaxis and pulmonary hemorrhage. A 13-year-old male child presented to the hospital with a six-month history of recurrent epistaxis and a one-month history of anemia. Routine blood tests demonstrated severe normocytic anemia and normal platelet count. Von Willebrand test revealed a significantly lower level. High-resolution chest computed tomography (CT) showed patchy ground glass opacities consistent with hemorrhagic changes. After ruling out the family history, the patient was diagnosed with AVWS. Additional tests confirmed positive antinuclear and anti-Sm antibodies. The underlying SLE was diagnosed and treated with methylprednisolone with disease recovery.

CONCLUSION

We recommend screening for bleeding disorders in patients with recurrent epistaxis. AVWS should be considered when laboratory findings suggest hereditary von Willebrand disease without a personal or familial history of bleeding. In addition, the underlying disease should be explored.

Are laboratory evaluations required in every case admitted to the pediatric emergency department with epistaxis?

BACKGROUND

Epistaxis is a mostly self-limiting condition common among children and is rarely severe. In this study, it was aimed to evaluate the incidence, demographic characteristics, causes of bleeding and treatment methods of patients who presented to the pediatric emergency department (PED) with epistaxis, and to determine in which cases a laboratory test should be used.

METHOD

Admitted to Gazi University Faculty of Medicine, PED which provides trauma care and is a tertiary hospital, from 1 January 2019 to 31 December 2019, 452 patients aged 0-18 years who presented with epistaxis for any reason or secondary to systemic disease were analysed retrospectively.

RESULTS

The annual incidence was found at 1.23%. The median age was 5.25 years, 258 of the cases (57.1%) were male. It was found that the cases most frequently applied to the hospital in the autumn months (37.6%). Sixty of the patients (13.3%) had a chronic disease and 54 (11.9%) had a history of drug use. Bleeding time was less than 5 minutes in 75.2% and 84.4% of the bleeding was unilateral. Nasal bleeding is local in 73.4%; 4.7% of them developed because of systemic reasons. The most common cause of epistaxis; while they were trauma at the first 10 years of age, they were idiopathic causes after the age of 10 years. In 434 (96%) of the patients, epistaxis spontaneously stopped and there was no need for additional treatment.

CONCLUSION

As a result of this study, it was concluded that laboratory tests should be performed in cases with chronic disease history, bilateral bleeding, active bleeding and nontraumatic epistaxis. The situation that causes epistaxis in the childhood age group should be determined with a good history and physical examination, laboratory tests should not be used in every patient.

Efficacy and Safety of Intranasal Medical Management in Pediatric Patients with Idiopathic Recurrent Epistaxis

Objective:

The goal of the study was to verify the efficacy and safety of topical medical treatment in idiopathic recurrent pediatric epistaxis patients by intranasal usage of both an antimicrobial and a moisturizing agent as a first-step management modality.

Method:

Sixty-seven out of 326 pediatric patients with idiopathic recurrent epistaxis selected on a chart review of follow-up were enrolled in the study. The study was designed as an analysis of two groups: one group included 35 individuals (52.2% of the total cohort) having a hyperemic nasal mucosa and the second group included 32 individuals (47.8% of the total cohort) having a hypervascular nasal mucosa on physical examination before treatment.

Results:

The study was performed with a total of 67 children (age range 3-17 years) including 36 males (53.7% of total cohort) and 31 females (46.3% of total cohort). The mean age was 9.78±4.09 years. There was not any statistically significant difference between the groups in terms of age, duration of follow-up and recurrence time of epistaxis (p>0.05). Recurrence of epistaxis was seen in 22.9% (8/35) of hyperemic nasal mucosa group and in 34.4% (11/32) of hypervascular nasal mucosa group (p>0.05).

Conclusion:

We advise the use of both an intranasal antimicrobial ointment and a mucosal moisturizing gel as an effective, noninvasive and easily applicable medical treatment option for pediatric patients with idiopathic recurrent epistaxis before more invasive methods of epistaxis control.

Clinical Practice Guideline: Nosebleed (Epistaxis)

OBJECTIVE

Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.

PURPOSE

The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary

OBJECTIVE

Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the great majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.

PURPOSE

The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include 1 or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome (HHT). (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation about examination of the nasal cavity and nasopharynx using nasal endoscopy was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

Plain Language Summary: Nosebleed (Epistaxis)

This plain language summary explains nosebleeds, also known as epistaxis (pronounced ep-ih-stak-sis), to patients. The summary applies to any individual aged 3 years and older with a nosebleed or history of nosebleed who needs medical treatment or wants medical advice. It is based on the 2020 "Clinical Practice Guideline: Nosebleed (Epistaxis)." This guideline uses research to advise doctors and other health care providers on the diagnosis, treatment, and prevention of nosebleeds. The guideline includes recommendations that are explained in this summary. Recommendations may not apply to every patient but can be used to help patients ask questions and make decisions in their own care.

Safety and efficacy of sphenopalatine artery ligation in recalcitrant pediatric epistaxis

BACKGROUND

Epistaxis is a common cause for emergency department visits for both children and adults. In particular, posterior bleeds can be difficult to identify and treat. In adults, endoscopic sphenopalatine artery (SPA) ligation has been shown to be safe, cost-effective, and curative. Conversely, very few studies have delved into the safety and efficacy of SPA ligation in children. This study aims to evaluate the feasibility of SPA ligation for treatment of recalcitrant epistaxis in children.

METHODS

A retrospective analysis of outcomes in pediatric patients who underwent SPA ligation at a tertiary academic center was performed. Patients with coagulopathies or other underlying conditions were excluded from the study.

RESULTS

Data obtained from 5 patients demonstrated 60% of the population were female, with ages ranging from 2 to 13 years. 7 SPA ligations were performed among the 5 patients, with 3 undergoing unilateral SPA ligation only. The remaining 4 underwent contralateral SPA ligation subsequently. No postoperative complications were observed, and all patients experienced resolution of significant epistaxis.

CONCLUSION

Although additional studies are necessary to further support our findings, SPA ligation in the pediatric population appears to be a safe and effective treatment to control persistent posterior bleeds.

Management of Epistaxis in Children and Adolescents: Avoiding a Chaotic Approach

This article provides an organized foundation that facilitates the management of acute epistaxis and an understanding of features that merit further diagnostic workup. Prompt management, including measures such as holding pressure and using nasal packing, takes precedence over comprehensive diagnostic workup. Severe, recurrent, and posteriorly based bleeds should prompt consideration of alternate interventions and expert consultation.

Current Approaches to Epistaxis Treatment in Primary and Secondary Care

BACKGROUND

The lifetime prevalence of epistaxis is approximately 60%, and 6-10% of the affected persons need medical care. In rare cases, severe bleeding calls for the rapid initiation of effective treatment.

METHODS

This review is based on pertinent articles that were retrieved by a selective search PubMed, and on the authors' clinical experience.

RESULTS

There are no German guidelines for the management of epistaxis. The available evidence consists mainly of retro spective analyses and expert opinions. 65-75% of the patients who require treatment can be adequately cared for by their primary care physician or by an emergency physician with baseline measures. If there is persistent anterior epistaxis, an otorhinolaryngologist can control the bleeding sastisfactorily in 78-88% of cases with chemical or electrical cauterization. Nasal packing is used if this treatment fails, or for posterior epistaxis. In a retrospective study, surgical treatment was found to be more effective than nasal packing in the treatment of posterior epistaxis (97% versus 62% treatment success). Percutaneous embolization is an alternative treatment for patients whom general anesthesia would put at high risk.

CONCLUSION

The treatment of severe or recurrent epistaxis requires the interdisciplinary collaboration of the primary care physician, the emergency physician, the practice-based otolaryngologist, and the hospital otolaryngology service. Uniform guidelines and epidemiological studies on this topic would be desirable.

Current and Emerging Options for the Management of Inherited von Willebrand Disease

Von Willebrand disease (VWD) is the most common inherited bleeding disorder with an estimated prevalence of ~1% and clinically relevant bleeding symptoms in approximately 1:10,000 individuals. VWD is caused by a deficiency and/or defect of von Willebrand factor (VWF). The most common symptoms are mucocutaneous bleeding, hematomas, and bleeding after trauma or surgery. For decades, treatment to prevent or treat bleeding has consisted of desmopressin in milder cases and of replacement therapy with plasma-derived concentrates containing VWF and Factor VIII (FVIII) in more severe cases. Both are usually combined with supportive therapy, e.g. antifibrinolytic agents, and maximal hemostatic measures. Several developments such as the first recombinant VWF concentrate, which has been recently licensed for VWD, will make a more "personalized" approach to VWD management possible. As research on new treatment strategies for established therapies, such as population pharmacokinetic-guided dosing of clotting factor concentrates, and novel treatment modalities such as aptamers and gene therapy are ongoing, it is likely that the horizon to tailor therapy to the individual patients' needs will be extended, thus, further improving the already high standard of care in VWD in most high-resource countries.