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| Topical TXA in Epistaxis |
Topical TXA in Epistaxis
Background: Epistaxis is a common Emergency Department (ED) complaint with over 450,000 visits per year and a lifetime incidence of 60% (Gifford 2008, Pallin 2005). Standard anterior epistaxis treatment consists of holding pressure, use of local vasoconstrictors, topical application of silver nitrate and placement of an anterior nasal pack. ED patients with epistaxis often fail conservative management and end up with anterior nasal packs which are uncomfortable. This is even more common in the group of patients who are taking antiplatelet agents like aspirin or clopidogrel. Recently, the use of topical tranexamic acid (TXA) has been described in patients with anterior epistaxis with shorter time to epistaxis control and shorter ED length of stay (Zahed 2013). However, prior studies have not focused specifically on patients taking antiplatelet agents.
Article:
Zahed R et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med 2017. PMID: 29125679
Clinical Question: Does application of topical TXA result in a higher proportion of patients with anterior epistaxis control at 10 minutes in comparison to anterior nasal packing.
Population: Patients (did not specify adults, pediatrics or both but assumed adults based on text) presenting to the ED of a single academic teaching hospital in Tehran, Iran with acute, new or recurrent ongoing anterior epistaxis who were currently taking antiplatelet drugs (aspirin, clopidogrel or both). Patients were included if they had continued epistaxis after 20 minutes of continued pressure.
Intervention: Tranexamic acid (TXA) soaked cotton pledget (500 mg TXA in 5 ml)
Control: Anterior nasal packing with cotton pledget soaked in epinephrine (1: 100,000) and lidocaine (2%)
Outcomes:
- (Primary): Proportion of patients in each group with stopped bleeding at 10 minutes
- (Secondary): Re-bleeding rate at 24 hours and one-week, ED length of stay (LOS), patient satisfaction
Design: Prospective, randomized, non-blinded, parallel group trial
Excluded: Patients with 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.
Primary Results:
- Patients enrolled
- n = 384 patients assessed for eligibility
- n = 124 patients who were included and randomized
- No patients lost to follow up for the primary or secondary outcomes
Critical Findings:
Strengths:
- Study asks a clinically relevant question regarding cessation of bleeding in epistaxis
- Data analysts were blinded to allocation
- Surpassed target sample size (57 patients needed in each arm to achieve 80% power to detect 25% difference in primary outcome)
- Follow up was complete (no patients lost)
Limitations:
- Unclear whether cessation at 10 minutes clinically more important than cessation at another interval. Additionally, nasal packing may take longer to achieve hemostasis based on mechanism making this particular comparison (primary outcome) unfair
- Physicians and patients non-blinded to intervention. Researchers indicate that the study wasn’t blinded because pharmacy prepared kits had differing numbers of cotton pledgets and the consistency, color and smell of the medications used for soaking could unblind groups
- Bleeding at 24 hours and one-week assessed in person or by phone. Authors do not specify how many assessed by each method. May introduce recall bias
- Majority of patients on aspirin only (> 80%). Though patients on clopidogrel included, results may not apply as well to this group
Authors Conclusions:
“In our study population, epistaxis treatment with topical application of TXA resulted in faster bleeding cessation, less re-bleeding at 1week, shorter ED LOS, and higher patient satisfaction as compared with ANP. “
Our Conclusions: Topical TXA resulted in a significantly higher rate of cessation of bleeding of anterior epistaxis within 10 minutes of application in comparison to anterior nasal packing in patients on antiplatelet agents (primarily aspirin). ED LOS and patient satisfaction were considerably better in the TXA group as well but these were secondary outcomes. Though this study is too small to comment on safety, there have not been any documented serious adverse effects of this approach in the published literature.
Potential to Impact Current Practice: The use of topical TXA is painless, non-invasive and relatively inexpensive. Providers should consider the use of this approach in patients with anterior epistaxis who fail direct pressure prior to placement of an anterior pack.
Bottom Line: The application of topical TXA appears to be a rapid and affective approach to achieving hemostasis in anterior epistaxis. Future studies should look at longer term outcomes and use in patients on anticoagulants or other antiplatelet agents.
References:
- Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. 2008;41:525-536. PMID: 18435996
- Pallin DJ et al. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med. 2005;46:77-81. PMID: 15988431
- Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013; 31: 1389-92. PMID: 23911102
Post Peer Reviewed By: Salim R. Rezaie (Twitter: @srrezaie)
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| Topical TXA in Epistaxis |
Epistaxis Management in the Emergency Department: A Helpful Mnemonic
February 15th, 2017 | ENT |4 Comments
By: Moises Gallegos, MD MPH
epistaxisEpistaxis is a common presentation to the emergency department (ED)1 that can be challenging and time consuming. Knowledge of the pearls, pitfalls, and troubleshooting tips around managing nosebleeds often can be the difference between a frustrating versus straightforward ED stay for patients. Use the EPISTAXIS mnemonic to help you remember these points.
Epistaxis Mnemonic
E xamine
Attempt to distinguish between anterior and posterior bleeding
P ressure
Apply pressure over the nose with compression device or fingers
I rrigate
Irrigate with warm water
S ilver nitrate
Apply silver nitrate locally, if anterior vessel identified
T ampons
Insert anterior nasal or posterior balloon tampons
A frin
Oxymetazoline can be sprayed in the nose as part of conservative treatment or applied on tampon
t X A
Apply TXA as gel or solution on tampon
I nterventional radiology
Contact interventional radiology for embolization in conjunction with ENT surgeon
S urgical consultation
Obtain an early ENT consult for severe or high risk bleeding
Anatomy
Anterior bleeding
Contributes to majority of cases
Occurs at the watershed area known as Kiesselbach’s plexus
Posterior bleeding
Contributes to severe cases
Arises from branches of the sphenopalatine artery (rare cases involve the carotid artery)
Etiology
Causes include direct trauma, nose picking, irritation, dryness
Associated with bleeding dyscrasia, congenital or traumatic arterio-venous malformations, anticoagulation, neoplasm
The majority of bleeding is self-limited and easily controlled.
Epistaxis Solutions in the ED
Recurrent or intractable bleeding has led to the development of management algorithms in the urgent care setting.2,3
Examine/Ensure secure airway
Attempt to visualize site of bleeding. Have patient gently blow nose to clear the clots. Obtain adequate lighting and use a nasal speculum, if available.
Pressure
As with any bleed, compression is key. Fatigue becomes an issue as patients tire of squeezing their nose. There are commercially available nasal compression clips, but in a pinch (get it?) you can create your own with tongue blades as demonstrated in this trick of the trade.
Irrigation
Irrigation of the nares can improve visibility. Warm-water irrigation has been demonstrated to facilitate hemostasis in posterior bleeds by causing mucosal edema that constricts vessels.4
Silver Nitrate/Cautery
If a bleeding anterior vessel is identified, an attempt at chemical or electrical cautery can be made. Silver nitrate sticks offer an easily accessible and efficacious option.5
Caution:
Avoid bilateral septal cautery to prevent septal perforation.
Carefully apply silver nitrate very focally on the mucosa being sure not to touch the skin, because it can accidentally burn and stain it (e.g. patient’s nasal ala) black.6
Tampons/Packing
Nasal tampons, often made of Merocel, are used for nasal packing. Patients may be pre-treated with topical lidocaine (2%) and/or oxymetazoline. Nasal tampons can be coated with bacitracin for lubrication before inserting along the nasal floor. Apply saline to expand the tampon. Tampons can also be inserted into the contralateral nostril for further compression.
Balloon catheter tampons provide an alternative option and can target posterior bleeding. They contain an internal balloon that is inflated for extra pressure. Such products have been shown to be easier to use and better tolerated; however, the efficacy is similar to Merocel tampons.7,8
If such balloon catheter tampons are not readily available for difficult cases of posterior bleeding, Foley catheters can be used.9 Insert a 10 or 12 French catheter so that the balloon lies in the nasopharynx. Inflate the balloon with 15 mL of saline, and then apply light forward traction on the catheter to tamponade the bleeding posterior vessels. If bleeding persists anteriorly or into the oropharynx, the balloon can be incrementally inflated up to 30 mL. Avoid inflation with air as the pressure can be lost over time.
Caution should be taken to avoid packing if there is concern for facial fractures.
Afrin/Medication
Oxymetazoline (Afrin), a selective alpha-1 adrenergic receptor agonist and partial alpha-2 receptor agonist, has been shown to be an effective vasoconstrictor even for posterior bleeding.10 Use cautiously in hypertensive patients because elevated blood pressure may contribute to further bleeding. One trick is to apply oxymetazoline directly onto the tampons after insertion. This allows cotton to expand while also providing vasoconstriction.
TXA
The use of tranexamic acid (TXA) in epistaxis and mucosal bleeding has been a topic of interest. While research is equivocal, studies are promising regarding TXA application for nasal packing.11–13 The TXA dosing in Zahed et al.’s paper was 500 mg in 5 mL, applied on the nasal tampon.11
Interventional Radiology or Surgery
ENT consultation should be obtained in a timely manner for severe, refractory bleeding that may require intravascular embolization or surgical ligation.
Disposition
Patients with posterior epistaxis and packing should be admitted to the hospital for observation and ENT consultation.14 These patients may be at higher risk for bradydysrhythmias and recurrent bleeding, requiring surgery. Patients with anterior epistaxis who are hemostatic can be discharged home, assuming stable laboratory testing and vital signs. If they have nasal tampons in place, arrange ENT follow-up at 24-48 hours for re-evaluation and removal of tampons. The routine use of antibiotics to prevent toxic shock syndrome and sinus infections remains debated.
1. Pallin D, Chng Y, McKay M, Emond J, Pelletier A, Camargo C. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med. 2005;46(1):77-81. [PubMed]
2. Traboulsi H, Alam E, Hadi U. Changing Trends in the Management of Epistaxis. Int J Otolaryngol. 2015;2015:263987. [PubMed]
3. Newton E, Lasso A, Petrcich W, Kilty S. An outcomes analysis of anterior epistaxis management in the emergency department. J Otolaryngol Head Neck Surg. 2016;45:24. [PubMed]
4. Novoa E, Schlegel-Wagner C. Hot water irrigation as treatment for intractable posterior epistaxis in an out-patient setting. J Laryngol Otol. 2012;126(1):58-60. [PubMed]
5. Shargorodsky J, Bleier B, Holbrook E, et al. Outcomes analysis in epistaxis management: development of a therapeutic algorithm. Otolaryngol Head Neck Surg. 2013;149(3):390-398. [PubMed]
6. Maitra S, Gupta D. A simple technique to avoid staining of skin around nasal vestibule following cautery. Clin Otolaryngol. 2007;32(1):74. [PubMed]
7. Badran K, Malik T, Belloso A, Timms M. Randomized controlled trial comparing Merocel and RapidRhino packing in the management of anterior epistaxis. Clin Otolaryngol. 2005;30(4):333-337. [PubMed]
8. Singer A, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Ann Emerg Med. 2005;45(2):134-139. [PubMed]
9. Ho E, Mansell N. How we do it: a practical approach to Foley catheter posterior nasal packing. Clin Otolaryngol Allied Sci. 2004;29(6):754-757. [PubMed]
10. Doo G, Johnson D. Oxymetazoline in the treatment of posterior epistaxis. Hawaii Med J. 1999;58(8):210-212. [PubMed]
11. Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013;31(9):1389-1392. [PubMed]
12. Kamhieh Y, Fox H. Tranexamic acid in epistaxis: a systematic review. Clin Otolaryngol. 2016;41(6):771-776. [PubMed]
13. Tibbelin A, Aust R, Bende M, et al. Effect of local tranexamic acid gel in the treatment of epistaxis. ORL J Otorhinolaryngol Relat Spec. 1995;57(4):207-209. [PubMed]
14. Supriya M, Shakeel M, Veitch D, Ah-See K. Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome. J Laryngol Otol. 2010;124(7):744-749. [PubMed]
Am J Emerg Med. 2013 Sep;31(9):1389-92. doi: 10.1016/j.ajem.2013.06.043. Epub 2013 Jul 30.
A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial.
Abstract
OBJECTIVE:
METHODS:
RESULTS:
CONCLUSIONS:
© 2013.
Comment in
- PMID:
- 23911102
- DOI:
- 10.1016/j.ajem.2013.06.043
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