Epistaxis in children — structured clinical encounter

A four-year-old boy is brought to the emergency department with brisk bleeding from the nose for twenty minutes. His father has him tilted backward in a chair pressing a towel against the bony bridge of the nose, and the child has just vomited a small amount of swallowed blood. He is pale but alert, heart rate 110, capillary refill two seconds. You are the paediatric registrar working through the correction of the first-aid errors, resuscitation, the stepwise escalation to cautery and packing, and a later scenario of a seven-year-old with recurrent epistaxis, easy bruising and a family history of bleeding.