CLINICAL PEARLS AND PITFALLS Nosebleeds are rarely life threatening and often need only basic measures to treat the bleeding Posterior nosebleeds are more difficult than anterior nosebleeds to control Laboratory workup is not indicated unless there is severe blood loss Epistaxis is a relatively common presentation to the ED Most nosebleeds are a result of repetitive trauma to the anterior portion of the nose, at a vascular confluence called Kiesselbach plexus ( Fig 118.8 ) Additional factors such as dry ambient air, nasal congestion secondary to allergic rhinitis, nasoseptal deformities, and other infections are also related to an increased risk of nosebleeds The physical examination is essential to identify abnormalities in general appearance, vital signs, airway, and color An approach to the management of epistaxis is provided in Figure 118.9 Continuous pressure applied to the soft tissues of the nose for to 10 minutes is usually sufficient, and should be applied with the patient sitting in the parent’s lap, if anxious, and with the head tilted forward Labs are infrequently indicated, unless there are concerning findings on history or examination For more information on nosebleeds, see Chapter 26 Epistaxis CONDITIONS OF THE LARYNX AND TRACHEA Goals of Treatment Supraglottitis and tracheitis are relatively rare but life-threatening illnesses that require rapid recognition and treatment Patients will typically present to the ED in extreme distress as evidenced by stridor and tripoding Both supraglottitis and tracheitis require prompt consultation by otorhinolaryngology See Chapter 94 Infectious Disease Emergencies for more details on recognition and treatment Suggested Readings and Key References Center for Disease Control and Prevention (CDC) Estimated burden of acute otitis externa—United States, 2003–2007 MMWR Morb Mortal Wkly Rep 2011;60(19):605–609 Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices Pneumococcal vaccination for cochlear implant