TXA for Epistaxis

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For patients on antiplatelet agents with epistaxis, tranexamic acid (TXA)-soaked pledgets were far more effective than lidocaine with epinephrine-soaked pledgets at stopping bleeding within 10 minutes and were better tolerated by patients.

Why does this matter?
Usual treatment for epistaxis is direct pressure, then topical vasoconstrictors plus pressure, or packing in refractory cases. Nasal packing is very uncomfortable for patients.  This small study looked at the antifibrinolytic TXA, used as a topical agent.

You’re shoving what up my nose?
This was a small RCT with 62 in each group, comparing a topical TXA-soaked pledget vs. a lidocaine 2% + epinephrine-soaked pledget in patients on antiplatelet agents (ASA or clopidogrel) with epistaxis.  Patients were included only if direct pressure for 20 minutes had failed.  For the primary outcome, cessation of bleeding in 10 minutes, TXA was far superior: 73% stopped vs only 29% with lidocaine + epi.  For secondary outcomes, TXA was also better at preventing rebleeding, and patients were more satisfied with it opposed to packing – no wonder.  They also had a shorter length of ED stay.  Clinicians were not blinded, which could have introduced bias in favor of TXA.  There is also an inconsistency in the paper.  The methods say TXA-pledgets were compared with lido + epi-pledgets, but the discussion says TXA was compared with tetracycline-impregnated pledgets.  Hard to know what they were shoving up patients’ noses.

Source
Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial.  Acad Emerg Med. 2017 Nov 10. doi: 10.1111/acem.13345. [Epub ahead of print]

Another Spoonful

• Sinai EM covered this article.
• Check this outstanding evidence-review guest post on REBEL EM on topical TXA for mucosal bleeding.

Peer reviewed by Thomas Davis, MD.