It’s a busy ER shift. Everyone seems pretty sick today. You get a patient into a back room of your emergency department with a pretty bad nosebleed. The patient is a relatively young, healthy guy, first time bleeder, or at least this is the first nosebleed he has ever had to seek medical attention for. He is not on anticoagulation or antiplatelet therapy. His only risk factor is that he gets his nose hairs waxed (ew, why?!). This gentleman has been bleeding from his left nare for about two hours prior to coming to the emergency room and he couldn’t control the bleeding with pressure alone. Vital signs are stable, and he doesn’t have any other complaints such as dizziness, nausea, or headache. What is your approach?
Why is epistaxis relevant, besides the fact that everyone loves Eleven from Stranger Things? Epistaxis is a very common ED complaint, with over 450,000 visits a year and a lifetime incidence of 60%. Six percent will require medical attention, so you’re bound to see it frequently. Ideally, you want to stop this nosebleed in a quick, but also comfortable, manner for the patient.
Is there any recent evidence backing up using tranexamic acid (TXA) for anterior epistaxis?
Moreover, is there evidence for use of TXA in patients on antiplatelet therapy?
Zahed R, Mousavi Jazayeri MH, Naderi A, Naderpour Z, Saeedi M. Topical tranexamic acid compared with anterior nasal packing for treatment of epistaxis in patients taking antiplatelet drugs: randomized control trial. Academic Emergency Medicine. 2018;25(3):261-266. [paper]
Multi-center (2 academic teaching hospital EDs in Tehran, Iran), prospective, randomized, non-blinded, parallel group trial.
- Intervention: TXA soaked cotton pledget (500 mg TXA in 5 ml) left in until bleeding stopped.
- Control: cotton pledget soaked in epinephrine (1: 100,000) and lidocaine (2%) for 10 minutes followed by anterior nasal packing covered w/ tetracycline ointment left
in for 3 days until removal.
- Eligible (n=384): acute new or recurrent anterior epistaxis and taking antiplatelet drugs (aspirin, clopidogrel or both) with ongoing bleeding after 20 minutes of
- Excluded (n=260): traumatic epistaxis, current anticoagulant use, history of bleeding or platelet disorders, INR >1.5, visible bleeding vessel that could be stopped with more
localized measures, history of renal disease, lack of consent.
- 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, Patient satisfaction
Ultimately, the researchers enrolled 124 patients and grouped them in control (n=62) and intervention (n=62) groups with no patients lost to follow up. Overall, the patients had very similar characteristics in the two groups. In both groups, a majority of patients were on aspirin alone. There was a higher history of prior epistaxis in the intervention group.
Patients on antiplatelet therapy can be treated with topical TXA for anterior epistaxis with improved cessation of bleeding and patient satisfaction. Number needed to treat of 2!
- Obviously this is a clinically relevant topic with impressive results.
- The researchers surpassed their target sample size for better power.
- There was no loss to follow up.
- Could not blind patients or physicians to the intervention.
- They assessed bleeding at 24hr and 1 week by phone or sometimes in person, which could cause recall bias.
- Over 80% of the patients were on aspirin only so the results may not apply to those on clopidogrel or both (DAPT) as well.
- There was no grading of epistaxis, so we don’t know if results vary depending on the severity of the bleed.
- This particular study does not cover posterior epistaxis, or compare to other commercial packing devices such as the rhino rocket, merocel, or epistat.
When dealing with anterior epistaxis I will definitely consider using topical TXA to stop the bleeding. It will get my patients discharged home sooner without invasive packing strategies. TXA is also typically readily available and inexpensive. While this is just one randomized control trial, it does support adopting this practice in patients on antiplatelet drugs.
By the way, with the patient from before, you ultimately used TXA to control the bleeding and the patient was discharged from the emergency room quickly without an anterior nasal packing. He vowed that he would never get his nose hairs waxed again.
Sophia Bodnar is an EM Resident, Class of 2019