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21st July 2022
Use of topical tranexamic acid within an emergency department (ED) for the treatment of epistaxis reduces the need for anterior nasal packing, the rate of stay for more than 2 hours in the ED and the incidence of re-bleeding 24 hours within 24 hours of admission. These were the key conclusions from a randomised trial by a team of Iranian researchers.
Epistaxis can occur in up to 60% of the population during their lifetime and which prompts approximately 6% of individuals to seek medical attention. One form of treatment for epistaxis is anterior nasal packing and which has been found to be effective in as many as 85% of cases. However, anterior nasal packing is associated with complications including pain during introduction and removal of pack, bleeding after removal due to mucosal damage and synechia formation. An alternative treatment is topical tranexamic acid while some data points towards a benefit from using topical tranexamic acid for epistaxis, others have found that there are no real benefits, particularly with respect to the time spent within an ED.
Given these disparities in the literature, for the present study, the Iranian team undertook a randomised, double-blind trial to examine whether the use of topical tranexamic acid reduced the need for anterior nasal packing in patients with active, spontaneous, atraumatic anterior epistaxis presenting at an ED. All patients were initiated treated with an ice pack applied to the back of their neck and continuous irrigation of the mouth with cold water for 10 minutes. However, when these approaches failed, individuals were randomised to either cotton pledgets soaked with topical tranexamic acid, phenylephedrine and lidocaine (intervention group) or the same treatment but without tranexamic acid (the control group). All medication was pre-packed and numbered so that both clinical staff and patients were unaware of their treatment allocation. If an individual had no bleeding for 30 minutes and were haemodynamically stable, they were discharged from the department. The researchers set the primary outcome as the use of anterior nasal packing at any time regardless of other treatments after the trial therapies. Secondary outcomes included the need for an ED stay longer than 2 hours, re-bleeding within 24 hours of the ED admission, as well as re-bleeding within the subsequent 1 to 7 days.
Topical tranexamic acid and anterior nasal packing
A total of 240 patients with a mean age of 52.5 years (52.5% male) were equally randomised between the two groups.
The need for anterior nasal packing occurred in 50% of those treated with topical tranexamic acid compared to 64.2% of those in the control arm, a difference that was statistically significant (odds ratio, OR = 0.56, 95% CI 0.33 – 0.94). Similarly, the intervention group were less likely to need to stay in the ED for more than 2 hours (OR = 0.38, 95% CI 0.18 – 0.82) or experience re-bleeding within 24 hours (OR = 0.41). However, there were no significant differences in the rate of re-bleeding 1 to 7 days after their admission to the ED.
The authors conclude that the use of topical tranexamic acid was a low cost, simple intervention for the control of bleeding in adults with spontaneous atraumatic anterior epistaxis.
Hosseinialhashemi M et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial Ann Emerg Med 2022