TXA Atraumatic Epistaxis

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Hosseinialhashemi M, et al. "Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial". Ann Emerg Med. 2022. online ahead of print:.
PubMed

Clinical Question

In adult patients with atraumatic anterior epistaxis, does the addition of tranexamic acid to standard of care (cotton pledget soaked with phenylephrine and lidocaine) as compared to standard of care for the need for anterior packing.

Bottom Line

The combination of topical application of tranexamic acid, phenylephrine, and lidocaine for 15 minutes lowered the rate of anterior packing by 14% and a shorter length of stay in Emerg.

Major Points

Atraumatic intractable epistaxis is a fairly common presenting complaint in Emerg. It is a common challenge for treatment as standard of care requires packing which can be uncomfortable for patients and requires further evaluation by a healthcare professional to remove the packing after several days. Tranexamic acid is comparatively inexpensive and has been used topically to control bleeding in a number of settings.[1] This trial used tranexamic acid 500mg soaked in cotton packing added to standard of care with epinepherine and lidocaine (n=120), compared to standard of care (n=120). The pledgets were removed after 15 minutes. The primary outcome of need for anterior packing occurred in 14% fewer patients (OR 0.56, 90% CI 0.33-0.94). Staying in Emerg for more than 2 hours occurred in 11.6% fewer patients (OR 0.38, 95% CI 0.18-0.82) who were received tranexamic acid topically and had 15% fewer rebleeding (OR 0.41, 95% CI 0.22-0.78) within in 24 hours.

These findings appear in opposition to the larger NoPAC trial where they sequentially treated patients with vasoconstriction and then TXA and outcomes were different. This trial had several limitations. There may have been some selection bias, first as the initial treatment prior to randomization was not protocolized and second this was conducted at an ENT referral centre. Finally a large proportion (65%) of patient went on to definitive treatment with cauterization. The available evidence is currently equivocal, addition of TXA may help and is likely not harmful in this indication.

Guidelines

As of September 2022, no guidelines have been published that reflect the results of this trial.

Design

  • Single-centre, double-blind, randomized, controlled trial
  • N=240
    • Tranexamic Acid (n=120)
    • Control (n=120)
  • Setting: ENT Emerg of a referral academic centre in Iran
  • Enrollment: Sept to Nov 2021
  • Follow-up: 7 days
  • Analysis: intention-to-treat
  • Primary Outcome: reduction in the need for anterior nasal packing

Population

Inclusion Criteria

  • Adult (18 years or older)
  • Spontaneous atraumatic anterior epistaxis
  • Referred to the ENT Emerg between 8:00 AM and 8:00 PM
  • Assessed by an ENT resident physician
  • Persistent epistaxis resistant to squeezing the soft area of their nose, applying an ice pack on the back of their neck, and continuously irrigating the mouth with cold water for at least 10 minutes

Exclusion Criteria

  • Unstable hemodynamics
  • Known allergy to tranexamic acid
  • unable / unwilling to consent
  • known nasal cavity
  • paranasal malignancy
  • pregnancy
  • out-of-hospital packing
  • known bleeding disorder
  • recent use of anticoagulant or clopidogrel
  • prisoner
  • proven or suspected posterior bleeding

Baseline Characteristics

Tranexamic Acid Group displayed

  • Demographics: 45% female, median age 52 years
  • Physiologic parameters: median systolic blood pressure 135 mmHg, median diastolic blood pressure 75
  • Use of ASA 28%

Interventions

  • Intervention: cotton pledget soaked with 5 mL of IV tranexamic acid 100 mg/mL; 10 mL (0.05 g) phenylephrine; and 5 sprays of 10% lidocaine spray (10 mg/spray), then inserted into affected nostril, removed after 15 minutes.
  • Control: same but did not include tranexamic acid

Outcomes

Comparisons are Tranexamic Acid vs. Control.

Primary Outcomes

Anterior nasal packing
50.0% vs. 64.2% (ARR 14.2% [95% CI 1.8-26.6]; OR 0.56 [95% CI 0.33-0.94])

Secondary Outcomes

More than 2 hours of stay in the ED
9.2% vs. 20.8% (ARR 11.6% [95% CI 2.8-20.6] OR 0.38 [95% CI 0.18-0.82])
Rebleeding within 24 hours
15.0% vs. 30.0% (ARR 15% [95% CI 4.6-25.4] OR 0.41 [95% CI 0.22-0.78])
Electrical cauterization
62.5% vs. 67.5% (absolute difference 5% [95% CI -7.0 to 7.0] OR 0.80 [95% CI 0.47-1.36])
Rebleeding within 1-7 days
7.5% vs. 13.3% (absolute difference 5.8% [95% CI -1.9 to 13.5] OR 0.53 [95% CI 0.22-1.25])

Adverse Events

None reported by authors

Criticisms

  • conducted at a speciality ENT Emerg and may not reflect common practice
    • 4500 patient visits per month, 300 for epistaxis
  • 65% of patients required electric cauterization, may indicate selection bias
  • Initial treatment prior to randomization was not protocolized and may have been suboptimal or inconsistent between cases

Funding

  • Vice Chancellor of Research of Shiraz University of Medical Sciences (grant number: 23337)

Further Reading