What is the best course of action for a 13-year-old patient (ILD) with 3 days of dizziness, loss of appetite (LOA), tiredness, general body pains, and a recent episode of epistaxis?

Evaluation and Management of a 13-Year-Old with Systemic Symptoms and Epistaxis

This adolescent requires urgent evaluation for a systemic illness, not just isolated epistaxis management—the constellation of 3 days of constitutional symptoms (dizziness, fatigue, body pains, loss of appetite) followed by epistaxis suggests either a primary hematologic disorder, severe infection, or other systemic pathology that warrants immediate laboratory workup and possible emergency department evaluation.

Critical Red Flags in This Presentation

The clinical picture here is concerning for several reasons that distinguish it from simple pediatric epistaxis:

• Constitutional symptoms preceding epistaxis (dizziness, generalized body pains, fatigue, loss of appetite for 3 days) suggest a systemic process rather than isolated nasal trauma 1
• Dizziness in the context of epistaxis may indicate hemodynamic compromise from blood loss or an underlying hematologic disorder 1, 2
• Adolescent age with unprovoked epistaxis requires consideration of juvenile nasopharyngeal angiofibroma in males (presents with profuse unilateral epistaxis in 60-76% of cases) or other pathology 3
• Bleeding disorders commonly present in this age group and may manifest initially as epistaxis combined with easy bruising or fatigue 1, 2

Immediate Assessment Required

Hemodynamic Evaluation

• Check vital signs immediately: assess for tachycardia, hypotension, or orthostatic changes that would indicate significant blood loss requiring hospital-level care 1
• Assess for pallor, prolonged capillary refill, or signs of shock—these indicate severe epistaxis requiring emergency intervention 1, 2

Bleeding History

• Document bleeding duration and severity: bleeding >30 minutes over 24 hours meets criteria for severe epistaxis 1, 2
• Personal or family history of bleeding disorders (von Willebrand disease, hemophilia, platelet disorders) must be elicited, as these are associated with severe pediatric epistaxis 1, 2
• Recent medications: antiplatelet agents or NSAIDs can contribute to bleeding 1

Systemic Illness Assessment

• Fever, night sweats, weight loss: may suggest malignancy or severe infection 4
• Petechiae, bruising, or other bleeding sites: strongly suggest hematologic disorder 2
• Unilateral vs bilateral epistaxis: unilateral epistaxis with nasal obstruction raises concern for tumor or foreign body 3, 1

Initial Management of Active Bleeding

If epistaxis is ongoing at presentation:

• Position upright with head tilted slightly forward to prevent blood from flowing into airway 1, 5
• Apply firm continuous compression to soft lower third of nose for full 10-15 minutes without interruption—this resolves the vast majority of anterior epistaxis 1, 5
• If bleeding persists after compression: apply topical vasoconstrictor (oxymetazoline or phenylephrine spray) directly to bleeding site after clearing clots, then resume compression for 5-10 minutes 1, 5
• Perform anterior rhinoscopy after clot removal to identify bleeding source 1, 5

Mandatory Laboratory Workup

Given the systemic symptoms, laboratory evaluation is essential and should not be delayed:

• Complete blood count with differential: to assess for anemia from blood loss, thrombocytopenia, or leukemia 2, 4
• Coagulation studies (PT/INR, aPTT): to screen for bleeding disorders, especially given the systemic symptoms 2
• Peripheral blood smear: if CBC shows abnormalities 4
• Consider von Willebrand panel if family history or recurrent bleeding 1

Indications for Emergency Department Transfer

This patient likely requires ED evaluation based on:

• Systemic symptoms lasting 3 days combined with epistaxis suggest possible severe underlying condition 1, 2
• Dizziness may indicate hemodynamic instability or significant blood loss 1, 2
• Need for laboratory workup and possible transfusion or factor replacement if bleeding disorder identified 2
• Severe epistaxis in pediatrics (defined as requiring factor replacement, transfusion, admission, or surgery) occurs in 8% of ED presentations and is associated with bleeding disorders 2

Special Considerations for Adolescents

Tumor Evaluation

• Adolescent males with unilateral, unprovoked, profuse epistaxis require examination of posterior nasal cavity and nasopharynx to exclude juvenile nasopharyngeal angiofibroma 3
• Nasal endoscopy is recommended if bleeding is difficult to control, recurrent, or associated with unilateral nasal obstruction 3, 1

Foreign Body

• Nasal foreign bodies present with unilateral epistaxis in 7% of pediatric cases and can cause delayed morbidity including infection and septal perforation 3
• Anterior rhinoscopy or nasal endoscopy should be performed to exclude foreign body 3

Common Pitfalls to Avoid

• Do not dismiss systemic symptoms: epistaxis alone is common in children (30% under age 5 have an episode), but constitutional symptoms preceding epistaxis warrant full evaluation 6, 2
• Do not assume simple anterior epistaxis: while 87-90% of pediatric epistaxis is anterior, the clinical context here demands investigation for underlying pathology 6, 4
• Do not delay laboratory workup: bleeding disorders are a significant risk factor for severe pediatric epistaxis requiring transfusion or admission 2
• Insufficient compression time: if attempting outpatient management, compression must be maintained for full 10-15 minutes without checking 1, 5

Follow-Up and Prevention

If bleeding is controlled and patient is stable for outpatient management after workup:

• Apply petroleum jelly or moisturizing agents to nasal mucosa to prevent recurrence 1, 5
• Regular saline nasal sprays to maintain mucosal moisture 1, 5
• Avoid nose picking, vigorous blowing, and strenuous activity 4
• Arrange follow-up within 30 days to assess outcome and review laboratory results 1
• Recurrent epistaxis despite appropriate treatment requires ENT specialist referral 1