1. Minor active bleeding. Have child sit up, lean forward over a basin or towel, and gently blow nose to rid nasal cavity of clots. Nostrils should be pinched, applying direct pressure to anterior septum, for a full 5 minutes. Should this fail, nasal cautery is indicated.
2. Active bleeding. Reassurance to calm all involved and allow for orderly treatment is important. Adequate support personnel, good lighting, and appropriate instruments must be available. To cauterize the anterior nasal septum, topical decongestion or analgesia is achieved using 4% lidocaine mixed with oxymetazoline. If bleeding site is located, silver nitrate sticks can be applied to the spot. Apply silver nitrate only to the area to be cauterized. Scar formation between lateral and medial nasal walls may result if both areas are cauterized. A small pledget of absorbable topical hemostatic agent soaked in oxymetazoline can be placed against the bleeding point and left in place if needed. Antibiotic ointment is instilled at the end of cautery. Use acetaminophen for analgesia. Given the risk of inhaling or choking on blood, conscious sedation should be avoided for control of active bleeding. In uncooperative children, general anesthesia allows effective management of bleeding in a controlled environment.
3. Packing. Rarely needed. Oral antibiotics are warranted when packing is used. In general, packs need to be removed in 48 hours.
4. Therapy to prevent bleeding. Directed at keeping mucosa moist. Frequent use of saline nose spray (at least 3-4 times daily) and twice-daily use of petroleum jelly prevents cracking and crusts and enhances healing of mucosa. If ambient environment is dry, an ultrasonic humidifier in bedroom is beneficial.
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