Epistaxis is a common presenting complaint to the Emergency Department, and Emergency Physicians are becoming increasingly interested in understanding the capabilities of tranexamic acid (TXA) to stop things from bleeding. In recent years, it seems we want to sprinkle that stuff on just about anything that bleeds…
So, what does the literature show in regard to the nose…
Study Title: A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial.
Study Design: RCT comparing topical application of injectable form of TXA (500 mg in 5 mL) to anterior nasal packing in 216 patients with anterior epistaxis presented to an ED.
Outcomes Measured: The time needed to arrest initial bleeding, hours needed to stay in hospital, and any rebleeding during 24 hours and 1 week later were recorded, and finally, the patient satisfaction was rated by a 0-10 scale.
Study Title: Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial.
Study Design: Randomized, parallel-group clinical trial of 124 patients conducted at two ED’s, evaluating topical TXA (500 mg in 5 mL) versus anterior nasal packing.
Things to consider about the Zahed et al. studies:
- Patients were INCLUDED if they had continued epistaxis after 20 minutes of continued pressure.
- Patients were EXCLUDED from study if they had a traumatic epistaxis, current anticoagulant drug use, inherited bleeding disorders, inherited platelet disorders, INR > 1.5, shock, a visible bleeding vessel, a history of renal disease and lack of consent.
- In the 2018 study, only 124 of 384 patients met eligibility, suggesting a poor representation of all cause epistaxis presenting to the ED.
- Patients with a visible bleeding vessel seems to be key here. Most nose bleeds I personally see in the ER are brisk enough that they seemingly would have been excluded from this study.
- Anterior packing doesn’t sound like it was a Rhino Rocket or other similar device.
Study Title: Evaluating Effectiveness of Nasal Compression With Tranexamic Acid Compared With Simple Nasal Compression and Merocel Packing: A Randomized Controlled Trial.
Study Design: Single-center, prospective, RCT was conducted with patients who had spontaneous anterior epistaxis to see which is faster at stopping anterior bleeding within 15 minutes.
- 135 patients enrolled (median age 60)
- Compared the effect of 3 treatment options:
- TXA with compression but without nasal packing
- Nasal packing (Merocel)
- Simple nasal external compression
Study Title: Tranexamic acid in epistaxis: a systematic review
Study Design: Systematic review of 3 RCT’s pertained to spontaneous epistaxis
Results:
-
- 1 trial found no benefit of oral TXA in acute epistaxis
- 1 trial found no significant benefit of topical TXA, but the largest of the trials showed significant benefit of topical TXA in acute epistaxis management.
- 2 RCTs examined oral TXA for prophylaxis of recurrent epistaxis in patients with hereditary hemorrhagic telangiectasia AND both showed significant reduction in severity and frequency.
Important considerations missing from this literature:
- Studies only assess ANTERIOR bleeding.
- Could there be benefit to IV TXA for hemodynamically significant posterior bleeds?
- No real data in regards to patients on anticoagulants or other antiplatelet agents as these patients were excluded from much of the current literature.
- Is there any increased risk of thrombosis with TXA use in at risk patients?
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