November 2024
A 3-year-old boy presents to the urgent care with epistaxis in his left nostril that has persisted for 20 minutes. There is mild to moderate bleeding, which is controlled partially by holding pressure. Bleeding resumes when pressure is released. He is becoming increasingly irritable, but he has no cough, fever, difficulty breathing, or pain. You ask the mother about medications, prior episodes of epistaxis, surgeries, or chronic conditions, as well as if he is exposed to tobacco smoke at home or if there is a family history of bleeding disorders or nasal conditions, all of which she denies.
You know you need to determine the source and location of bleeding in this young boy, but he has decided to become uncooperative. With the mother’s permission, you administer 2.5 mg midazolam intramuscularly to calm him down. Wearing protective equipment, you apply oxymetazoline spray up his nostril to slow the bleeding so you can examine his nasal passage with a speculum and headlamp. You see a foreign body.
Which of the following is the most appropriate next step?
- Perform nasal endoscopy to locate and remove the foreign body
- Refer immediately to otolaryngology for surgical removal
- Apply nasal cauterization to stop the bleeding before attempting removal
- Attempt the “parent’s kiss” technique or positive pressure ventilation
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Answer: d. Attempt the “parent’s kiss” technique or positive pressure ventilation
Conclusion and follow-up: The “parent’s kiss” technique involves a caregiver blowing into the child’s mouth while blocking the unaffected nostril to expel the foreign body through positive pressure. It is a noninvasive first-line approach that can be effective for visible and uncomplicated foreign bodies in young children. You explained the procedure to the mother, and she was willing to try it. After successfully performing the technique, a black-eyed pea came out of the boy’s nose.
Most cases of epistaxis in young adults are benign, especially if associated with recent nasal irritation. This patient was discharged with nasal care instructions that included avoiding nose picking or blowing her nose forcefully, using a saline nasal gel or humidifier to keep her nasal passages moist, and following up with an otolaryngologist if further episodes occur.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
