How do we treat persistent epistaxis (nosebleed) in children that doesn't stop bleeding?

Treatment of Persistent Epistaxis in Children

For persistent epistaxis in children that continues despite initial measures, apply firm sustained nasal compression to the lower third of the nose for at least 5 minutes, and if bleeding persists, use topical vasoconstrictors followed by nasal packing with resorbable materials if the child has bleeding risk factors. 1

Immediate Management Algorithm

Step 1: Proper Nasal Compression (First-Line Treatment)

• Position the child sitting upright with head tilted slightly forward to prevent blood from entering the airway or being swallowed 2, 3
• Apply firm, sustained digital compression to the soft lower third of the nose for a minimum of 5 minutes without interruption 1
• The compression must be continuous—do not check if bleeding has stopped before 5 minutes, as this is a common pitfall that leads to treatment failure 2
• Have the child breathe through their mouth and spit out any blood rather than swallowing it 2, 3
• Compression alone controls the majority of pediatric epistaxis cases, including those presenting to emergency departments 1, 2

Step 2: Add Topical Vasoconstrictors if Compression Fails

• If bleeding continues after 5 minutes of compression, clear clots from the nose and apply a topical vasoconstrictor such as oxymetazoline (Afrin) or phenylephrine 1, 3
• Spray 2 times into the bleeding nostril, then resume firm compression for an additional 5 minutes 2
• Vasoconstrictors can be applied via nasal spray or cotton pledgets soaked with the medication inserted into the nose 1
• This approach stops bleeding in 65-75% of cases treated in emergency departments 3, 4
• While obtaining history during compression, ask specifically about: medications (especially anticoagulants/antiplatelets), personal history of bleeding disorders, family history of bleeding disorders, and recent nasal procedures 1

Step 3: Nasal Packing for Refractory Bleeding

• If bleeding precludes identification of a bleeding site despite nasal compression and vasoconstrictors, proceed to nasal packing 1
• For children with suspected bleeding disorders or those on anticoagulation/antiplatelet medications, use resorbable packing materials specifically 1, 2
• Resorbable packing reduces the likelihood of additional bleeding when removed compared to non-resorbable materials 1
• Non-resorbable options include petroleum jelly-impregnated gauze, PVA nasal tampons (Merocel), or balloon systems (Rapid-Rhino) 4
• Newer hemostatic materials like hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan), or fibrin glue are more effective with fewer complications 4

Indications for More Aggressive Management

Proceed beyond compression and packing when: 1

• Bleeding fails to stop or slow with compression
• The nosebleed is judged to be life-threatening
• Continued bleeding occurs out the nose or into the posterior pharynx during compression (suggests posterior bleeding site)
• Bleeding duration exceeds 30 minutes over a 24-hour period 2
• The child shows signs of hemodynamic instability such as tachycardia or hypotension 2

Advanced Treatment Options (Specialist Consultation Required)

Nasal Cautery

• Requires anesthesia of the bleeding site with topical lidocaine or tetracaine applied via spray or cotton pledgets 1
• Restrict cautery application only to the active or suspected bleeding site(s) to minimize risk of septal perforation 1
• Young children and uncooperative patients may require sedation or general anesthesia 1
• Electrocautery is more effective than chemical cauterization, with recurrence rates of 14.5% versus 35.1% 3, 4
• Bilateral cautery should be used selectively and cautiously to minimize septal perforation risk 1

Tranexamic Acid (Emerging Option)

• Topical tranexamic acid (TXA) has shown higher rates of acute bleeding control compared to anterior nasal packing in emergency department studies 1
• However, the guideline notes that additional study is needed to fully understand indications and efficacy, as most studies are of moderate quality 1

Prevention of Recurrence

Once bleeding is controlled: 2, 3

• Apply moisturizing or lubricating agents such as petroleum jelly to the nasal mucosa
• Use saline nasal sprays regularly to keep nasal mucosa moist
• Consider humidifier use, especially in dry environments
• Instruct the child to avoid nose picking or rubbing to allow healing

Critical Pitfalls to Avoid

• Insufficient compression time: Must maintain pressure for full 5 minutes minimum without checking 2
• Premature checking: Interrupting compression to see if bleeding stopped restarts the process 2
• Using non-resorbable packing in high-risk patients: Children with bleeding disorders or on anticoagulants require resorbable materials 1, 2
• Bilateral cautery without caution: Increases risk of septal perforation 1
• Neglecting prevention: Failing to address nasal mucosa dryness leads to recurrent episodes 2

When to Seek Specialist Consultation

Refer to otolaryngology when: 2, 3

• Bleeding persists after 15 minutes of continuous proper compression
• The child experiences dizziness from blood loss
• Nasal packing fails to control bleeding
• Recurrent epistaxis occurs despite preventive measures
• Endoscopic evaluation, arterial ligation, or embolization may be needed

Special Pediatric Considerations

• Most pediatric epistaxis is mild and self-limited, with only 5% requiring cautery or packing and 8% requiring more intensive intervention 5
• Risk factors for moderate epistaxis in children include older age, prior ED visit within 72 hours, and antiplatelet medication use 5
• Risk factors for severe epistaxis include bleeding disorders, nasal procedures within 30 days, and anticoagulation use 5
• Bleeding duration over 30 minutes prior to arrival is associated with both moderate and severe epistaxis 5