TXA for Epistaxis

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Zahed R. "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):1389-92.
PubMedFull text

Clinical Question

In adult patients that present to Emerg with anterior epistaxis, was local application of tranexamic acid superior to antibiotic ointment coated packing for arresting of bleeding?

Bottom Line

Use of topical application of injectable tranexamic acid was superior to standard packing in terms or arrest of bleeding within 10 minutes, faster discharge from Emerg, with a decreased rate of rebleeding within the first 24 hours or 7 days.

Major Points

Non-traumatic 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, compared to vasoconstriction with epinepherine and lidocaine, followed by packing that was removed after 3 days. In this trial 71% in the transexamic group had bleeding arrest within 10 minutes compared to 31% (P<0.001). Discharge within 2 hours occurred in 95% of the tranexamic acid group compared to 6% (P<0.001). Additionally patients preferred the tranexamic acid treatment.

Similar to the follow up trial by the same group, TXA for Epistaxis with Antiplatelet, there are several limitations with this trial. The first was the untrue blinding of the participants and the clinicians. There was also an inbalance between the two groups with more history of epistaxis in the tranexamic acid group. Finally the primary outcome is unclear: in the tranexamic acid group the packing was removed every 5 minutes to assess for arrest of bleeding whereas in the anterior packing group the evaluation was not described but the packing was removed after 3 days. Given the wide availability of this drug and the ease this trial suggests of use, this is a promising treatment for anterior epistaxis.

Guidelines

As of March 2018, no guidelines have been published that reflect the results of this trial.

Design

  • randomized, single-center, parallel group clinical trial
  • N=216
    • Tranexamic Acid (n=107)
    • Anterior packing (n=109)
  • Setting: Single centre in Iran
  • Mean follow-up: 7 days
  • Analysis: Intention to treat
  • Primary Outcome: Time to arrest bleeding

Population

Inclusion Criteria

  • Anterior Epistaxis
  • Adults

Exclusion Criteria

  • epistaxis following major trauma
  • posterior epistaxis
  • bleeding disorder: thrombocytopenia, hemophilia, and platelet disorders
  • international normalized ratio greater than 1.5
  • shock
  • visible bleeding vessel
  • idiopathic etiology
  • recurrent anterior epistaxis
  • previous intervention entered in this study

Baseline Characteristics

Tranexamic Acid group shown

  • Demographics: Mean age 50 years, 63% male
  • Labs: platelet 294, PT 12.4 seconds, INR 1.08, PTT 33 seconds
  • History of epistaxis 58%

Interventions

  • Tranexamic Acid 500mg/5mL soaked cotton packing, removed after bleeding arrest
  • Anterior Packing: soaked in epinephrine (1:100000) + lidocaine (2%) for 10 minutes, then packing covered with tetracycline removed after 3 days

Outcomes

Comparisons are anterior packing vs. Tranexamic Acid.

Primary Outcomes

Bleeding stop time ≤10 min,%
31 vs. 71 (OR 2.28, 95% CI 1.68-3.09, Effect Size 0.398, P < 0.001)

Secondary Outcomes

Discharge time ≤2 h, %
6 vs. 95 (OR 14.8, 95% CI 7.2-30.4, Effect Size 0.889, P < 0.001)
Rebleeding in the first 24 h, %
13 vs. 5 (OR 0.36, 95% CI 0.14-0.98, Effect Size -0.144, P = 0.034)
Rebleeding in 1 week, %
11 vs. 3 (OR 0.26, 95% CI 0.07-0.88, Effect Size -0.161, P = 0.018)
Patient satisfaction rate (Visual analogue scale)
4.4 ± 1.8 vs. 8.5 ± 1.7 (P < 0.001)

Adverse Events

Complications in the ED (Nausea/vomiting and intolerance), %
11 vs. 4.7 (OR 0.42, 95% CI 0.16-1.16, Effect Size -0.118, P < 0.128)
Serious adverse events
none reported either arm

Criticisms

  • Full blinding was not conducted due to product and protocol differences, only analysts were blinded
  • Excluded major risk factors for bleeding in this study, imiting external validity
  • Severity of epistaxis not classified
  • Higher rate of history of epistaxis in Tranexamic group
  • Complication of "intolerance" not well defined
  • Assessment of primary outcome unclear, tranexamic acid was assessed every 5 minutes but anterior packing was done on day 3

Funding

  • Not stated

Further Reading

  1. Ker K et al. Topical application of tranexamic acid for the reduction of bleeding. Cochrane Database Syst Rev 2013. :CD010562.