The AAP has endorsed a new clinical practice guideline on nosebleeds (epistaxis), which account for 0.5% of all emergency department visits and an untold number of visits to pediatricians and primary care physicians.
Clinical Practice Guideline: Nosebleed (Epistaxis) and supplementary materials were published by the American Academy of Otolaryngology‒Head and Neck Surgery Foundation and focus on patients ages 3 years and older. Available at http://bit.ly/39Vm8UM, the guideline represents the first multidisciplinary, evidence-based guideline on nosebleed developed in the United States.
While some of the recommendations deal with care provided by otolaryngologists, several action statements apply to primary care providers. Initially, the clinician should determine which patients have active bleeding that requires prompt management as opposed to those with bleeding that has slowed or stopped spontaneously.
In actively bleeding patients, the clinician should assure airway adequacy and then apply firm, sustained pressure to the lower third of the nose for at least five minutes, maintaining the patient’s head flexed slightly forward in a “sniffing” position. This technique will slow or control many nosebleeds.
While applying pressure, additional history can be obtained and risk factor assessment can be performed. Inquire about prior episodes of epistaxis, family history of bleeding disorders and use of anti-platelet or anticoagulant medications.
If the bleeding persists, the pediatrician should visualize the nasal mucosa with a nasal speculum or otoscope and attempt to identify the source of the bleeding. Once a site has been identified, topical application of a vasoconstrictor — such as oxymetazoline, epinephrine or phenylephrine — can be performed by applying a cotton pledget to the bleeding site. Cauterization of the bleeding site also can be accomplished by applying a silver nitrate applicator (CPT code 30901). Care must be taken to keep the applications brief and to avoid bilateral cautery, which carries a risk of nasal septal perforation.
Persistent bleeding should be referred to an otolaryngologist who can perform nasal endoscopy, packing and, if necessary, surgical ligation to stop bleeding episodes. Pediatricians also should be aware that recurrent epistaxis may represent hereditary hemorrhagic telangiectasia syndrome and are advised to pay particular attention to patients with a family history of epistaxis.
Finally, pediatricians can educate parents and patients about the prevention of nosebleeds, advising them to avoid nasal trauma and nose picking. Recommendations include use of humidification of inspired air and the application of lubricants such as saline and ointments to the nasal lining.
Dr. Hackell is a co-author of the guideline and a member of the AAP Section on Administration and Practice Management Executive Committee.